THE JOYFUL REDUCTION OF UNCERTAINTY

Navigating And/Or Avoiding The Inpatient Mental Health System

Apology and disclaimer

This is in response to questions I get about how to interact (or not interact) with the inpatient mental health system and involuntary commitment. The table of contents is:

1. How can I get outpatient mental health care without much risk of being involuntarily committed to a hospital?
2: How can I get mental health care at a hospital ER without much risk of being involuntarily committed?
3. I would like to get voluntarily committed to a hospital. How can I do that?
4. I am seeking inpatient treatment. How can I make sure that everyone knows I am there voluntarily, and that I don’t get shifted to involuntary status?
5. How can I decide which psychiatric hospital to go to?
6. I am in a psychiatric hospital. How can I make this experience as comfortable as possible?
7. I am in a psychiatric hospital and not happy about it and I want to get out as quickly as possible. What should I do?
8. I am in the psychiatric hospital and I think I am being mistreated. What can I do?
9. I think my friend/family member is in the psychiatric hospital, but nobody will tell me anything.
10. My friend/family member is in the psychiatric hospital and wants to get out as quickly as possible. How can I help them?
11. How will I pay for all of this?
12. I have a friend/family member who really needs psychiatric treatment, but refuses to get it. What can I do?

I am a psychiatrist, which both means I have some useful experience here, and makes it hard for people trying to avoid the system to trust me. Anything written with too much honesty risks degenerating into “here’s how to cheat the system so nobody will know you’re about to commit suicide”. But anything written with too little honesty risks degenerating into some variation of “trust the wise benevolent doctors to do what is best for you”. This is an impossible edge to balance on, and I am sure I fail at one point or another.

But my first excuse is that if somebody doesn’t understand how the commitment system works, they’re not going to innocently blunder into spilling their guts. They’re just going to never go to the psychiatrist at all. If someone wants to avoid ending up in the hospital but doesn’t know how, it’s not like they’re stuck doing everything we want. They can just lie about everything. Or they can just never go to the psychiatrist at all. If they understand a little bit about how the system works, they can at least lie strategically, in the one place where they have to lie, while cooperating 99% of the way.

And my second excuse is that in the end, this is not an adversarial enterprise. Psychiatrists commit people because they’re scared. They’re scared because they can’t predict what the patient is going to do – and on another level, they’re scared because they might get sued if they don’t follow the rules. If patients who aren’t going to hurt themselves know how to explain that they aren’t going to hurt themselves in a way that reassures their psychiatrist, and in a way that doesn’t leave their psychiatrist legally liable for not committing them, then everybody can be more comfortable and get on with the hard work of actual treatment.

This guide applies to adult mental health care only. Child/adolescent mental health care is totally different and I don’t know anything about it. I have only worked in two states, it might be a bit different in other states, and it is definitely a lot different outside the US. Nothing in here is official medical advice. Follow it at your own risk. Please don’t use this to avoid psychiatric care which you actually need. All of this will be wrong in certain situations; when in doubt, trust your intuition.

1: How can I get outpatient mental health care without much risk of being involuntarily committed to a hospital?

Mental health care is divided into inpatient and outpatient settings. Inpatient care means it’s in a hospital, voluntary or otherwise. Outpatient care is your local doctor’s office, or psychiatrist’s office, or therapist’s office.

If you go to a hospital for mental health reasons, your risk of getting involuntarily committed is relatively high – see below for more. If you go to an outpatient provider, your risk is much lower.

In theory, the outpatient system is supposed to provide voluntary treatment, with risk of involuntary commitment only in certain very clearly delineated situations that you can understand and avoid. Each state’s laws are slightly different (and I can’t say anything about non-US countries), but they tend to allow involuntary commitment only in cases of immediate risk of hurting yourself, hurting someone else, or being so psychotic that you could plausibly hurt someone by accident (eg you jump out of a window because you think you can fly).

The key word is “immediate”. If you just have occasional thoughts about suicide, or you have some limited hallucinations but remain grounded in reality, according to the law this is not enough to involuntarily commit you.

In practice, not every mental health professional knows the laws or interprets them the same way, so they can just commit you anyway. The check on this is supposed to be that you can sue them when you get out of the hospital, but almost nobody bothers to do this, and judges and juries usually find in favor of the mental health professional.

So the law isn’t as much protection as it probably should be. In reality your best protection is to only open up to competent people whom you trust, and to frame what’s going on in a way that doesn’t scare them unnecessarily.

Don’t joke about committing suicide. Don’t bring up occasional stray suicidal thoughts if they don’t matter. Don’t say something like “I think about suicide sometimes, but doesn’t everyone?”, because your psychiatrist will have heard the last ten people answer “No, of course I never think about suicide”, and they will not be impressed with your claim about the human condition. Assume that any time you mention suicide, there’s a tiny but real chance of getting committed. If you are actually suicidal, take that chance in order to get help. Otherwise, this is really not the time to bring it up. If you wouldn’t offhandedly chat about terrorism with an airport security guard, don’t offhandedly chat about suicide with a psychiatrist.

(none of this applies to competent psychiatrists whom you trust, but award this status only after many positive experiences over a long-term relationship)

If your psychiatrist asks you outright if you ever have suicidal thoughts, well, tough call. If you don’t, then say you don’t. If you mostly don’t but you are some sort of chronically indecisive person who has trouble giving a straight answer to a question, now is the time to suppress that tendency and just say that you don’t. If you do, but you would never commit suicide and it’s not a big part of why you’re seeing them and you don’t mind lying, you can probably just say you don’t. If you do, and it’s important, and you don’t want to lie about it, then make sure to be very specific about how limited your thoughts are (eg: “I only thought that way once, three years ago) and to add as many of these as are true:

1. “Of course I would never go through with it, but sometimes I think about…”
2. “I love my friend/family member/partner/pet too much to ever go through with it.”
3. “I don’t have any plans for how I would do it.”
4. “I’m [religion], and we believe that God doesn’t want us to commit suicide.”
5. “I’ve been thinking about it for [long time], but the thoughts haven’t gotten any worse lately.”

The same applies to hallucinations and other signs of psychosis. Most people have very minor random hallucinations as they are going to sleep. Most people hear their own thoughts as silent “voices” in their head at least some of the time. Most people who take hallucinogenic drugs will hallucinate. You don’t need to bring these up when someone asks you about hallucinations. If you actually have some troubling psychotic symptoms, then mention them, but add as many of these as are true:

1. “Of course, I know these aren’t really real.”
2. “These have been going on for a while and aren’t any worse lately.”
3. “I would never listen to anything the voices say.”
4. “I only get that way when I’m on drugs / really tired / under a lot of stress.”

If you do all of these things, your chance of getting involuntarily committed to a psychiatric hospital by an outpatient provider is probably one percent or less, unless you’re really really sick.

Notice the words “by an outpatient provider” here. None of this applies if you are in a hospital (eg with pneumonia). If you are in a hospital, be extra careful about this to the point of paranoia. Unless you’re really worried that you might go through with suicide, be careful about mentioning it the hospital. Get your pneumonia or whatever treated, and then go out of the hospital, find a competent outpatient psychiatrist whom you trust, and open up about your issues to them. If you decide to open up to the nurse-assistant giving you a three question psychiatric screen in the pneumonia ward, you may end up on a psychiatric unit regardless of how careful you are, because hospitals don’t take chances.

2: How can I get mental health care at a hospital ER without much risk of being involuntarily committed?

Hospital ERs are not set up to provide psychiatric help to random people. They are set up to evaluate people and decide if it’s a real emergency. If it is, you will be committed to an inpatient unit. If it isn’t, they will tell you to see an outpatient psychiatrist, and you will be back at the beginning except with an extra $5000 bill to pay.

This is not true 100% of the time, and you can take your chances if you want. In particular, if you have extreme anxiety, sometimes they can give you enough fast-acting anti-anxiety medication to calm you down and last you until you can see an outpatient psychiatrist. But going to a hospital ER for any mental-health-related reason other than expecting to get admitted to a hospital psychiatric unit should be a last resort.

3. I would voluntarily like to get committed to a hospital. How can I do that?

If you have a competent outpatient psychiatrist whom you trust, call them up and tell them what’s going on. If they have connections at a local hospital, they may be able to get you directly admitted, which will save you a lot of time and suffering.

Otherwise, you will have to go to a hospital ER. Be prepared for this to be extremely unpleasant. It may take up to 24 hours of sitting in the ER before a psychiatrist can see you. You will probably get examined by nurses, medical students, non-psychiatrist doctors, etc, and each time you will think “Finally! I am getting evaluated and I can get out of this ER!” but you will be wrong. Although there will probably be some crappy food and drink available, there may not be much in the way of entertainment, quiet, or privacy. Do yourself a favor and bring a book or game or something. You may not be allowed to keep your cell phone or laptop or other metal object (more on this later). If family or friends are willing to help, have them come along – if only so they can go out and bring you back real food when you get hungry.

Once you set foot in an ER and mention the word “psychiatry”, you should be prepared for someone to tell you that you’re not allowed to leave until the evaluation is complete. Maybe no one will tell you this, and you can try to leave, and it’ll be fine. But you should be prepared for it not to work.

After many trials and tribulations, you will be examined by a psychiatrist, who will decide whether or not to accept you to the psychiatric unit. You are not guaranteed admission to the unit just because you want it. You might be turned down if the psychiatrist thinks you aren’t sick enough to need it, or if your insurance refuses to pay for it. Insurance companies are very reluctant to pay for hospitalizations unless there is a clear risk involved, so explain what the risk is.

The only thing that (almost) always works is mentioning suicide. If you say you’re suicidal, you will get admitted. If you want to be sure, do the opposite of everything above. Stress that you are suicidal. Stress that it’s not just the occasional fleeting thought, but actually something that you might really go ahead with. If you have a plan, share it.

If you’re not suicidal, expect to have to argue. Talk about what you’ve already tried and why it didn’t work. Talk about all the damage your mental illness has caused in your life. If there’s any chance you might snap and do something horrible – hurt someone, hurt yourself, have some kind of spectacular breakdown – play it up. If you have to, say something vague like “I don’t know what I would do if I couldn’t get help”. Be ready for this not to work, and for the psychiatrist evaluating you to recommend you go to an outpatient psychiatrist.

If you really want help beyond the level of outpatient treatment, but your insurance company won’t budge, ask about a partial hospital program. This is something where you go to a hospital-like environment from 9 to 5 for a few weeks, seeing doctors and getting therapy and classes, but you’re not involuntarily committed and you go home at night. Sometimes insurance companies will be willing to do this as a compromise if you are not suicidal.

4. I am seeking inpatient treatment. How can I make sure that everyone knows I am there voluntarily, and that I don’t get shifted to involuntary status?

I want to be really clear on this: in your head, there might be a huge difference between voluntary and involuntary hospitalization. In your doctor’s head, and in the legal system, these are two very slightly different sets of paperwork with tiny differences between them.

It works like this, with slight variation from state to state: involuntary patients are usually in the hospital for a few days while the doctors evaluate them. If at the end of those few days the doctors decide the patient is safe, they’ll discharge them. If, at the end of those few days, the doctors decide the patient is dangerous, the doctors will file for a hearing before a judge, which will take about a week. The patient will stay in the hospital for that week. 99% of the time the judge will side with the doctors, and the patient will stay until the doctors decide they are safe, usually another week or two.

Voluntary patients are technically allowed to leave whenever, but they have to do this by filing a form saying they want to. Once they file that form, their doctors may keep them in the hospital for a few more days while they decide whether they want to accept the form or challenge it. If they want to challenge it, they will file for a hearing before a judge, which will take about a week. The patient will stay in the hospital for that week. 99% of the time the judge will side with the doctors, and the patient will stay until the doctors decide they are safe, usually another week or two.

You may notice that in both cases, the doctors can keep the patient for a few days, plus however long it takes to have a hearing, plus however long the judge gives them after a hearing. So what’s the difference between voluntary and involuntary hospitalization? Pride, I guess, plus a small percent of cases where the doctors just shrug and say “whatever” when the voluntary patient tries to leave.

Some decent fraction of the time, patients who intended to get voluntarily hospitalized end up involuntarily hospitalized for inscrutable bureaucratic reasons. The one I’m most familiar with is the ambulance ride: suppose the hospital you’re in doesn’t have any psychiatric beds available and wants to send you to the hospital down the road. For inscrutable bureaucratic reasons, they have to send you by ambulance. And for inscrutable bureaucratic reasons, any psychiatric patient transferred by ambulance has to be involuntary. Your doctors don’t care about this, because they know that there is no practical difference between voluntary and involuntary – but if you are still trying to maintain your pride, this might come as kind of a shock.

Some other decent fraction of the time, patients who ought to be involuntarily hospitalized end up voluntarily hospitalized for inscrutable bureaucratic reasons. The one I’m most familiar with is doctors asking patients whom they are committing against their will to sign a voluntary form, ie “Agree to come voluntarily, or else I will commit you involuntarily”. This sounds super Orwellian, but it really is done with the patient’s best interest at heart. Involuntary commitments usually leave some kind of court record, which people can find if they’re searching your name for eg a background check – which could come up anywhere from applying for a job, to trying to buy a gun. Voluntary commitments usually don’t cause this problem. Even though nobody feels very warmly to the psychiatrist telling them to sign voluntarily or else, that psychiatrist is right and you should suck it up and sign the voluntary form.

If given a choice, you should sign voluntary, if only for the background-check reason above. But don’t count on getting the choice, and don’t get too attached to the illusion that it really matters in some deep way.

5. How can I decide which psychiatric hospital to go to?

If it’s an emergency, the answer is “whichever one is closest” or even “whichever one the ambulance you should call right now takes you to.”

If you have a little more leeway, and you have a competent outpatient psychiatrist whom you trust, ask them which one to go to. They will probably be familiar with the local terrain and be able to give you good advice.

If you live in a big city with wealthier and poorer areas, and it’s all the same to your insurance company, try to go to a hospital in the wealthier area. Not only do wealthier people always get nicer things, but – and sorry if this is politically incorrect – you would rather be locked up for a week with the sorts of people who end up in wealthy-area psychiatric hospitals than with the sorts of people who end up in poor-area psychiatric hospitals.

US News & World Report ranks the best psychiatric hospitals. They’re mostly looking at doctor prestige, but I would guess this correlates with other factors patients want in a hospital. If you’re really prestigious you have a lot of money and a lot of eyes watching you, and that probably helps. I suspect teaching hospitals are also good, for the same reason. But these are just guesses.

If you have no other way of figuring this out, you can try looking at Psych Ward Reviews. This site is underused and suffers from the expected bias – you only write about somewhere if you don’t like it – but it’s better than nothing.

Keep in mind that sometimes hospitals will be full, and they will send you to a different hospital instead, and you will not have any say in this.

6. I am in a psychiatric hospital. How can I make this experience as comfortable as possible?

When you go to the hospital ER to get admitted, bring a bag of stuff with you. This should include clothing, fun things to do like books, earplugs, snacks you like, and phone numbers for people you might want to contact.

Keep in mind that you will not be allowed to have anything that could be used as a weapon, for a definition of “could be used as a weapon” which is clearly aimed at MacGyver-level masterminds who can create a railgun out of three paperclips and a stick of gum. The same goes for anything that could be used as a suicide method. This means for example no laced shoes, pillowcases, scarves, and a bunch of other things you will not expect. Basically, bring stuff to the hospital, but expect a decent chance it won’t be allowed in.

Metal objects, including laptops, cell phones, mp3 players, etc, will never be allowed in. These will be taken from you and put in a locker during your stay. If for some reason you have to transfer hospitals during your stay, these things always somehow get lost. Your best bet is to bring a friend with you to the ER, and have them take your cell phone and other valuables.

If you forget to bring a bag of stuff, or if you were committed involuntarily and unexpectedly and didn’t get a chance, call a friend or family member and ask them to bring you your stuff.

7. I am in a psychiatric hospital and not happy about it and I want to get out as quickly as possible. What should I do?

Good news: average stays for psychiatric hospitals have been decreasing for decades, and are now usually a week or less. I did a study on the hospital I worked in and came up with an median stay of 5.9 days, and remember that there are a lot of really sick people bringing up those numbers.

(there are a few states that have laws centered around the number “three days”, but there are also a lot of states that don’t. For some reason the “three days” number has leaked into the general consciousness and everyone expects that to be how long they stay in the hospital. Don’t necessarily expect to get out of the hospital in exactly three days, but do expect it will be closer to 5.9 days than to weeks or months.)

Even better news: contrary to rumor, psychiatrists rarely have a financial incentive to keep people hospitalized. In fact, most hospitals and insurances now encourage quick “turnover” to “open up beds” for the next group of needy patients, and doctors can get bonuses for getting people out as quickly as possible. This should worry everyone else in the hospital who’s getting treated for pneumonia or whatever, but from the perspective of a psychiatric patient who wants to leave quickly it’s pretty good.

If you have a good doctor, you should trust their judgment and do what they say. But if you have a bad doctor, then the only thing you can count on is that they will respond to incentives. Their incentive to get you out quickly is the hospital administrators and insurance companies breathing down their neck. Their incentive to keep you longer is that if you get out of the hospital and ever do anything bad, they can get sued for “missing the signs”. So their goal is to do a token amount of work that proves they evaluated you properly so nothing that happens later is their fault.

That means they’ll keep you for some standard time interval, traditionally (though not always) three days, just so they can say they “monitored” you. If you seem unusually scary in some way, they might monitor you a little longer, up to a week or two. Your chances of successfully convincing them not to do this are essentially nil. Imagine you kill someone a few weeks after leaving the hospital, and during the trial the prosecutor says “The patient was taken to St. Elsewhere Hospital for evaluation of mental status, but discharged early, because he said he didn’t want to have to sit around and be evaluated for the usual amount of time, and his doctor thought this was a reasonable request.” Your doctor is definitely imagining this scenario.

Instead of pleading with your doctors to let you go early, just do everything right. Have meals at mealtime. Go to groups at group time. Groom yourself, not just because you look saner when you’re well-groomed, but because there will actually be nurses monitoring your grooming status and reporting it to the psychiatrists making release decisions. When people tell you things you should do after leaving the hospital, agree that you will definitely do them. If people ask you questions, give reassuring-sounding answers.

For this last one – don’t contradict evidence against you, don’t accuse other people of lying, just downplay whatever you can downplay, admit to what the doctors already believe, and make it sound like things have gotten better. For example, if you were found lying face-down with an empty bottle of pills next to you, don’t say “I didn’t attempt suicide, I just tripped and the pills fell into my mouth!” (I have seriously had patients try this one on me). Don’t say “It was my girlfriend’s fault, she drove me to do it!” Just say something like “That was a really bad night for me, and I don’t remember exactly what happened, but now I’m feeling a lot more hopeful, and I think that was a mistake.”

Don’t overdo it. Nothing is more annoying than the person who’s like “The twenty minutes I’ve been talking with you so far have turned my life around, and now I realize how wrong I was to reject God’s beautiful gift of existence, and am overflowing with abounding joy at the prospect of getting to go back into the world and truly confront my problems with the help of my loving family and…” Just be like “Yeah, things were rough, but I feel a little better now.”

Most important, take the damn drugs.

Yes, I know that some psychiatric drugs are unpleasant or addictive or dangerous or make you feel miserable. I’m not challenging your decision not to want to be on them. But take the damn drugs while you are in the hospital, for 5.9 days. Then, when they let you out, decide if you still want to continue. I guarantee you this will be easier for you, for your psychiatrist, and for the various judges and lawyers involved. The alternative is that you refuse to take the drugs, somebody has to set up a court hearing to get an involuntary treatment order, you have to sit in the hospital for weeks while the legal system gets its act together, the psychiatrists finally get the order and drug you against your will, and then after however many weeks or months, you get released from the hospital and stop taking the drugs.

If you have a good doctor whom you trust, then talk to them about the drugs and make a decision together. Let them know if there are any side effects. If a drug isn’t working for you, tell them, so they can switch it. Be honest, and willing to stand up for yourself, but also open-minded and ready to listen.

But if you have a bad doctor, just take the damn drugs. Bring up side effects, mention anything that’s intolerable, but when – like bad doctors everywhere – they ignore you, just take the damn drugs. Then, when you get out of the hospital, go to a competent outpatient psychiatrist whom you trust, tell them the drugs aren’t right for you, and talk it over with them until you come up with a better plan.

This is a good general principle for everything: agree to whatever people ask you while you’re in the hospital, talk to a competent outpatient psychiatrist whom you trust once you get out, and decide which things to stick to. I remember working with a doctor who wanted to discharge his patient to some kind of outpatient drug rehab. The patient refused to go, so the doctor wouldn’t discharge her, and they were in a stalemate over it for weeks, and the whole time the patient was tearfully begging the doctor to release her. I cannot tell you how much willpower it took not to sneak into the patient’s room and yell at her “JUST AGREE TO GO TO THE REHAB AND THEN DON’T DO IT, YOU IDIOT”. I mean, I am as in favor of Truth as everyone else, but I don’t even think her doctor cared if she went to the rehab or not. He just wanted to be able to document “Patient agreed to go to rehab”, so that when she started taking drugs again, he would have ironclad court-admissable evidence that it wasn’t his fault.

Finally, your doctors will be very interested in “discharge planning”, ie making sure you have somewhere safe to be after you leave the hospital. They may not be willing to believe you about this. So get a family member (best) or friend (second-best) on your side. Have them agree to tell the doctors that they will watch over you after you leave, make sure you take your medication, make sure you get to your follow-up outpatient psychiatrist appointments, make sure you don’t take any illegal drugs. Your best bet for this is your mother – psychiatrists love mothers. Tell your doctors “I talked to my mother, she’s really concerned about my condition, she says that I can stay with her after I leave and she’s going to watch me really closely and make sure I’m okay”. Only say this if it’s true, because your doctors will call your mother and make sure of it. But if you can make this work, this is really helpful.

Even if all of this works, it’s just going to get you out of the hospital in a bit less than 5.9 days instead of a bit more than 5.9 days. There’s no good way to get out instantly. Sorry.

8. I am in the psychiatric hospital and I think I am being mistreated. What can I do?

Your best bet is to find someone with a position like “Recipient Rights Representative” or “Patient Rights Advocate”. Most states mandate that all psychiatric hospitals have a person like this. Their job is to listen to people’s concerns and investigate. Usually the doctors hate them, which I take as a pretty good sign that they are actually independent and do their job. If you haven’t already gotten a pamphlet about this person when you were admitted, ask the front desk or your nurse or someone else who seems to know what’s going on how to contact this person.

You may be able to switch doctors or nurses. Just go to the front desk or someone else official-looking and ask. I don’t think this is a legally codified right, but sometimes nobody cares enough to refuse. Keep in mind that if you switch doctors, you may have to stay longer so that the new doctor can do their three-day-or-so assessment of you, separate from the last doctor’s three-day-or-so assessment.

Threats don’t work. Everybody makes threats, and everyone at the hospital is used to them. Threatening to hire a lawyer is especially boring and overdone and will not even get anyone’s attention.

Actually hiring a lawyer will definitely get people’s attention, but it’s a high-variance strategy. Remember that it’s very hard to get a doctor not to hold you for a three-day-or-so evaluation, and that most people are released before anything goes to court anyway (a court hearing can take weeks to set up). I have mostly seen this work in cases where I have no idea what the doctors are thinking and everybody seems sort of confused and just letting the patient sit in the hospital for no reason. Lawyers can be a very good incentive for people to un-confuse themselves. I am not a lawyer, I have tried to avoid the state of prolonged confusion where lawyers become necessary, and I don’t want to give any legal advice beyond saying it will definitely get people’s attention. But I would feel bad if someone read this, hired a lawyer, found them not to be genuinely helpful (as in fact they probably will not be), and then got a huge legal bill.

Some people wait until they get out, then comparison-shop from the outside world and hire a lawyer to sue the people who mistreated them in the past. If you’re going to do this, document everything. Your doctors are documenting everything, and if one side comes in with perfect documentation and the other side just has vague memories, the first side will win. By “document everything”, I mean have a piece of paper where you write down things like “2:41 PM on October 10: Nurse Roberts threw a pencil at me. Informed such-and-such a person and they refused to help. Informed such-and-such another person and they also refused to help.” Write down exactly where and when everything took place – the psychiatric hospital may have video surveillance, and if everybody knows which videos to get, it will make life much easier. Report everything to the Patient Rights Advocate, even if they’re useless, just so you can call them up and have them testify you reported it to them at the time. I am not a lawyer, this is not legal advice, and your lawyer will be able to tell you much more – but documentation never hurts.

If things are really bad, figure out if there are surveillance cameras, and hang out in front of them.

Once you leave the hospital, consider giving feedback. Most hospitals will have some kind of survey or hotline or something that lets you praise hospital staff whom you liked and report hospital staff whom you didn’t like. This won’t heal any wounds you suffered – and while in the hospital, threatening to report a doctor will be ignored just like all threats – but it might help somebody way down the line. You can also write a report on Psych Ward Reviews. In fact, do this anyway, whether you’re mistreated or not, so that other people can learn which hospitals don’t mistreat people.

9. I think my friend/family member is in the psychiatric hospital, but nobody will tell me anything.

Yes, this definitely sounds like the sort of thing that happens.

Because of medical privacy laws, it is illegal to tell a person’s friend or family that they are in the psychiatric hospital, or which psychiatric hospital they’re in, without their consent. If the person is too paranoid, angry, or confused to give consent, then their friends and family won’t have a good way to figure out what’s going on.

Your best bet is to call every psychiatric hospital that they could plausibly be in and ask “Is [PERSON’S NAME] there?” Sometimes, all except one of them will say “No”, and one of them will say “Due to medical privacy laws, we can’t tell you”. I know this sounds ridiculous, but it really works.

Once you have some idea which hospital your friend is in, call and ask to speak to them. They will say something like “Due to medical privacy laws, we can’t tell you if that person is here.” Say “I understand that, but could you please just ask them if they’re willing to speak to me right now?” If they are willing to speak to you, problem solved. Otherwise, you might still get some information based on whether the person leaves you on hold for a while in a way that suggests she’s going to your friend and asking them whether they want to talk to you.

You can also ask to speak to (or leave a message for) the doctor taking care of your friend. The receptionist will say “Due to medical privacy laws, we can’t tell you if that person is here.” Say “I understand that, but I have some important information about their case that I want the doctor to know. They don’t need to tell me whether my friend is there or not, just listen.” At this point, all but the most committed receptionists will either admit that your friend isn’t there, or actually get a doctor or take a message. There is no doctor in the world who is so committed to medical privacy that they will waste time listening to the history of a patient they don’t really have just to maintain a charade, so if you actually get a doctor this is a really strong sign.

Once you have a good idea where your friend is, you can ask the receptionist to pass a message along to them, like “Call me at [this phone number]”. If they still don’t respond – well, that’s their right.

Most hospitals will have visiting hours. Going to visit someone who refuses to let you know they’re at the hospital and refuses to give anyone consent to talk to you is a high-variance strategy, but you can always try.

10. My friend/family member is in the psychiatric hospital and wants to get out as quickly as possible. How can I help them?

First, make sure they actually want to get out as quickly as possible, and you’re not just assuming this. You would be surprised how many people miss this step.

Second, make sure they know everything in section 7 here.

Third, offer to talk to the doctors. Doctors often don’t trust mentally ill patients, but they usually trust family members. If your friend isn’t sick enough to need to be in the hospital, tell the doctors that. Describe the circumstances around their admission and why it’s not as bad as it looks. Mention how well you know the person, and how you’ve been with them through their illness, and how you know they would never do anything dangerous. Only say this if it’s true – if they’re in the hospital for stabbing a police officer, your “they would never do anything truly dangerous” claim is just going to make you look like an idiot.

Offer to help with discharge planning (see the end of section 6). Tell them that the patient will be staying with you after they leave the hospital, that you’re going to be watching them closely to make sure that they’re safe, that you’ll make sure they take their medications and go to followup appointments. Again, only say this if it’s true – or at the very least, coordinate with the patient, so you don’t say “My son will be staying with me under my close supervision.” and then your son ruins it all by saying “Haha, as if.”

If you have a sob story, tell it. If you are ninety-seven years old and your son is the only person who is able to take care of you and bring you to your doctors’ appointments, mention that. Sob stories from patients generally don’t work, but sob stories from family members might.

Offer to come to the hospital during visiting hours and meet with the doctors. This both underlines everything above – it shows you’re really invested in their care – and also gives you a good opportunity to pressure the doctors face to face. I don’t mean you should threaten them or be a jerk about it, but just ask “Why can’t Johnny come home? We really need Johnny at home to help with the chores. Everyone at home misses Johnny.” I don’t guarantee this will work, but it will work a little, on certain people.

If there are many people in your family who are willing to work on this, use whoever is closest to the patient (eg their mother) – and in case of a tie use the person who is the most upstanding high-status member of society. A promise to take care of someone sounds better coming from a family member who is a doctor themselves (or a lawyer, or a teacher) compared to from the patient’s unemployed stoner brother with a NO FEAR tattoo.

As somebody who is not in a psychiatric hospital, you are in a much better position to hire a lawyer if one needs to be hired. Again, in the majority of cases a patient won’t even stay long enough to have a court hearing. If you are poor and have limited resources, this is definitely not how I would recommend using them. But if you have money to burn, or your friend/family member is being held for an inexplicable amount of time (longer than a week or two) and you don’t know why, you are going to be in a much better position to take care of this than the patient themselves.

Even if all this works, it’s just going to make someone stay a bit less than 5.9 days instead of a bit more than 5.9 days. There’s no good way to get someone out instantly.

11. How will I pay for all of this?

If you don’t have health insurance, there is usually some kind of state/county mental health insurance program that is supposed to help with this kind of thing. You usually have to earn below a certain amount to qualify. Your social worker at the hospital can talk to you about this. I am not promising you such a program will exist – if you’re concerned about money, look into this before you go to the hospital.

If you do have health insurance, they may pay for your admission. The problem is that they have to decide if you are really ill enough to need psychiatric care, and they make this determination separately from the doctors who decide whether to commit you or not. In the worst case scenario, you can be involuntarily committed because your doctors decided you needed care, but your health insurance refuses to pay for it because they decided you didn’t need care. If this happens, you are stuck with the bill. This is horrifying and there should be some kind of law against it, but I’ve seen it happen and I think it’s legal.

Your best bet in these cases is to try to get the state/county mental health insurance mentioned above. Sometimes you can sign up for it after you leave the hospital, and then get your costs reimbursed.

If everything goes wrong, and you’re stuck with a bill and no insurance company willing to pay it, try to argue the hospital down. Hospitals know that the average random sick person can’t afford to pay $20,000 or whatever ridiculous amount they charge. They make these numbers up as part of a complicated plot to fool insurance companies into overpaying, which never works, and they expect patients to try to bargain. They are also usually willing to consider whatever payment plan you think you can make work. I don’t know very much about this, but there’s some more information here.

As far as I know, committing people involuntarily and leaving them with a huge bill is legal, and hiring a lawyer will not help with this. I don’t know much, so you may want to ask a lawyer’s opinion anyway, if you can afford it.

12. I have a friend/family member who really needs psychiatric treatment, but refuses to get it. What can I do?

If your family member is not a danger to themselves or others, your options are limited. You can try to convince them to voluntarily seek treatment, but if it doesn’t work, it doesn’t work.

If your family member is a danger to themselves or others, you have a good case for getting them involuntarily committed to the hospital. A good example of this would be them threatening to hurt you, or actually hurting you, or being so out of touch with reality that you are legitimately afraid they might hurt you or themselves. Them being paranoid (“people are out to get me”) or extremely confused about basic reality (“I am able to fly”) counts as legitimate reason to believe they might hurt you or themselves. If this describes your family member, document everything worrying that they say or do so you can present it to the doctors doing the assessment and (eventually) the courts.

Then, if your family member is cooperative/confused enough to let you drive them to the hospital, drive them to a hospital ER. If they’re not this cooperative, call the police and they will take things from there. Be prepared for the police to potentially put your family member in handcuffs and be really aggressive and police-y about it (and if you have a dog, arrange for it to be somewhere else at the time – like stuck in a bedroom with the door closed). The police will bring your family member to the hospital ER. You should go to the hospital ER too, so that you can tell the doctors what’s wrong and why you think they need treatment – ie why they are dangerous or potentially dangerous.

The most common way this ends is that your family member goes to the hospital, is started on some drugs, gets a little better, goes home, stops taking the drugs, and gets worse again. If the doctors at the hospital are not competent, they may not think about this. It may end up being your job to insist on some kind of longer-term solution.

If your family member is psychotic, then the gold standard for longer-term solutions is a long-acting injectable antipsychotic medication. This is a shot that a nurse can give them which will give them a few months’ worth of antipsychotics all at once, safely. This way they don’t have to remember/agree to take their medication at home. Then a few months later you can wrangle them back to a doctor’s office where someone can give them the shot again; repeat as needed. If your family member doesn’t agree to this, you’re going to need a judge’s order – but judges are really cooperative with this kind of thing and your psychiatrist can tell you more about how to make this happen. A partial hospital program can also help with this.

There is a kind of institution with different names everywhere, usually something like “Assertive Community Treatment”, which basically consists of some mental health professionals in a van who go around to people’s houses and make sure they’re okay / staying on medication after they’ve been discharged from the hospital. These are chronically underfunded and you have to fight to get into them, but if nothing else works you can see if there’s one of them in your area. These people are also good at wrangling patients to get their monthly dose of long-acting injectable antipsychotics.

If you need a quick way to deal with a family member’s psychosis, and they refuse to take antipsychotic medicine, and they don’t meet criteria for involuntary hospital admission – well, I can’t believe I’m saying this, and this is super not medical advice – but cannabidiol, a chemical in marijuana, is a weak but functional antipsychotic. Normal marijuana is awful for this situation and contains lots of other chemicals that make psychosis worse, but you can get special cannabidiol-only strains that act sort of like weak non-prescription antipsychotic medication. In a state like California where marijuana is legal, you can talk to a marijuana expert about which strains these are and how to use them. In a state where only medical marijuana is legal, you can take your family member to a random quack to get them a medical marijuana card, then follow the same process. Most psychotic people refuse to believe that they are psychotic, but most of them are very anxious. If you frame the marijuana as a way to help with their anxiety, they may go along with it. Then they might get non-psychotic enough to make them understand there’s a problem, after which they can go to a psychiatrist and get a longer-term solution. Again, this is definitely not medical advice and if you have any other options you should take those instead.

You can get a lot more (and much more responsible) advice from the Treatment Advocacy Center, a non-profit that helps people figure out how to get their friends and family members psychiatric treatment.

Postscript

All of this is to prepare you for worst-case scenarios. Many people seek inpatient mental health treatment, find it very helpful, and consider it a positive experience. According to a survey on Shrink Rap (heavily selected population, possibly brigaded, not to be taken too seriously) about 40% of people who were involuntarily committed to psychiatric hospitals eventually decided it was helpful for them. This fits my experience as well. Be careful, but don’t avoid getting treatment if you really need it.

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208 Responses to Navigating And/Or Avoiding The Inpatient Mental Health System

  1. Well since I’m me, I am contractually obligated to respond to this in an accusatory manner, so here goes:

    Anything written with too much honesty risks degenerating into “here’s how to cheat the system so nobody will know you’re about to commit suicide”.

    You say that like it’s a bad thing.

    And my second excuse is that in the end, this is not an adversarial enterprise. Psychiatrists commit people because they’re scared. They’re scared because they can’t predict what the patient is going to do – and on another level, they’re scared because they might get sued if they don’t follow the rules. If patients who aren’t going to hurt themselves know how to explain that they aren’t going to hurt themselves in a way that reassures their psychiatrist, and in a way that doesn’t leave their psychiatrist legally liable for not committing them, then everybody can be more comfortable and get on with the hard work of actual treatment.

    AHAHAHAHAAHAHAHAHAHAHAHAHAHAAHAHAHAHAHAHAHAHAHAAHAHAHAHAHAHAHAHAHAAHAHAHAHAHAHAHAHAHAAHAHAHAHAHAHAHAHAHAAHAHAHAHAHAHAHAHAHAAHAHAHAHAHAHAHAHAHAAHAHAHAHAHAHAHAHAHAAHAHAHAHAHAHAHAHAHAAHAHAHAHAHAHAHAHAHAAHAHAHAHAHAHAHAHAHAAHAHAHAHAHAHAHAHAHAAHAHAHAHAHAHAHAHAHAAHAHAHAHAHAHAHAHAHAAHAHAHAHAHA are you serious? “This person gets sued if I go on to do anything bad regardless of whether they’re in any way responsible, so they’ll lock me up and drug me in order to cover their ass” is, like, the textbook definition of “adversarial.” Speaking of which, why they fuck would any sane legal system do that?

    Don’t joke about committing suicide. Don’t bring up occasional stray suicidal thoughts if they don’t matter. Don’t say something like “I think about suicide sometimes, but doesn’t everyone?”, because your psychiatrist will have heard the last ten people answer “No, of course I never think about suicide”, and they will not be impressed with your claim about the human condition. Assume that any time you mention suicide, there’s a tiny but real chance of getting committed. If you are actually suicidal, take that chance in order to get help. Otherwise, this is really not the time to bring it up. If you wouldn’t offhandedly chat about terrorism with an airport security guard, don’t offhandedly chat about suicide with a psychiatrist.

    This… really is not inspiring confidence in the system’s ability to show restraint and only commit people when absolutely necessary. If you’re at the point of comparing an organization to the TSA, then perhaps you might want to consider whether said organization is really necessary or sane.

    FInally… okay look, I talk about this problem a lot, but my suicidality doesn’t really fit the model of “short term with a serious plan” vs “long term with out one.” I have done a fair amount of planning, and have considered killing myself in complete seriousness, but I haven’t ever (yet) concluded that I ought to go through with it. So committing me is going to do next to nothing, and only incentivizes me to be dishonest and avoid treatment that I might actually need. As far as I can tell, there’s no way for me to say “I think suicide might possibly be the right choice, but I want to take my time deciding and exhaust all other options first” and have that actually be respected, since “you can always decide to kill yourself later” is never actually true given the doctor’s position here. And, of course, saying all this to a doctor or other staff member is only going to make me look combative and dangerous.

    /rant, for now

    • Scott Alexander says:

      I think it’s not adversarial insofar as both you and your psychiatrist can cooperate in creating an environment in which you don’t say the things that your psychiatrist could be sued for not committing you if you say, thus fulfilling both of your preferences.

      “This… really is not inspiring confidence in the system’s ability to show restraint and only commit people when absolutely necessary. If you’re at the point of comparing an organization to the TSA, then perhaps you might want to consider whether said organization is really necessary or sane.”

      The goal of this post was definitely not to say that everything about the system is sane.

      • I think it’s not adversarial insofar as both you and your psychiatrist can cooperate in creating an environment in which you don’t say the things that your psychiatrist could be sued for not committing you if you say, thus fulfilling both of your preferences.

        I feel like you’re underestimating the degree of conflict here. My current situation, as far as I can tell, is one in which I can’t actually do therapy properly without saying the things I’d have to be committed for saying. In fact, I find it difficult to even forge a decent therapeutic alliance without the therapist/psychiatrist/whatever saying things that they could get into serious trouble for saying. Hinting at a need for validation in the form of “Yes, you have a right to bodily autonomy; yes it’s both okay and necessary to take an open-minded, skeptical view of whether life is worth living; and yes, you should be allowed to make big, perhaps socially unapproved decisions based on your conclusions” is forcing my psychiatrist to choose between either dodging the question or openly speaking heresy. So while they may in fact be looking to create a mutually agreeable outcome, our options are limited, and those limitations do create conflict between helping me and avoiding liability.

        (I don’t necessarily blame any individual psychiatrist for choosing the safe route here, but that doesn’t mean that things aren’t fucked up. I know that you are aware that the system is fucked up, but I think we disagree on just how fundamental the problem is. This isn’t just the sort of poorly-thought-out bureaucratic rules that you find in any other part of the healthcare system.)

        (Edit: So that I’m not just spewing negativity here, I do want to thank you for taking the time to make this post.)

        • ledflyd says:

          An issue you may not be considering is that a mutually agreeable exchange that is acceptable to you may not be to your relatives after you’re gone.

    • AnteriorMotive says:

      The point of this post isn’t to defend the system, it’s to help you navigate it safely.

      If you want treatment but don’t want to be involuntarily committed, now you know which parts to emphasize and what not to mention.

      “my suicidality doesn’t really fit the model of ‘short term with a serious plan’ vs ‘long term with out one.'”
      Is it a dichotomy, or are any one of these traits individually a risk factor?

    • Deiseach says:

      Don’t bring up occasional stray suicidal thoughts if they don’t matter.

      Re: suicidal thoughts, possibly an unfair question (trying to get free medical advice) but what is a good way (or is there a good way) to raise the question of “I have occasional suicidal thoughts and sometimes they get worse but since I’ve had them for literally decades there’s no or very little likelihood I’ll ever act on them, so don’t worry that I’m going to go out and throw myself into the river, and since I really don’t want to kill myself they probably don’t matter but at the same time how can I stop having them, because it’s really very tiresome tiring no fun at all nearly constantly having ‘I wish I was dead, I should kill myself’ going on in your head?”

      Like, if the best advice I’m going to get is “Have you tried not thinking suicidal thoughts?”, then fair enough, but it’s between the Scylla of “pshaw, you haven’t even attempted slitting at least one wrist ever? nothing is the matter and stop wasting my time!” and the Charybdis of “admitted to being suicidal, time for commitment”.

      • Murphy says:

        “I have occasional suicidal thoughts” vs “nearly constantly having ‘I wish I was dead, I should kill myself’ going on”

        Not a psychiatrist but if I heard the combination of the above I might worry that the first sentiment was said mainly to placate me while the latter was the reality.

        But I get what you mean. How to express that no, it’s spectacularly unlikely you’ll do anything about it but it’s still there.

        Not sure how to solve your problem but I hope you find something that helps because that sounds like something that sucks to experience.

        I hope someone can offer some actual advice to you and that it turns out something straightforward like a few mg of some antidepressant is enough to help.

      • Tamar says:

        I would frame it as “I have intrusive negative thoughts. Some are on the subject of suicide. I’ve had this type of intrusive thought for a long time and I’ve never made a plan to kill myself or in any other way acted suicidal because of them. I feel confident I don’t actually want to kill myself. I’m pretty sure that’s not going to change. Do you have any ideas for treatment or therapy options for very negative intrusive thoughts?” You might even be able to get into the subject of intrusive thoughts without specifying that any of them are on the subject of suicide to start with. I would just put the emphasis on the fact that you perceive and process these as negative intrusive thoughts (which are on the subject of suicide, when it comes down to details) and not as ‘suicidal thoughts’.

      • scrunchythief says:

        Hi, I’ve also had similar thoughts for about 2 decades, and I’ve had some help in therapy, and recently had a major break-through with medication. I also had the complication that I was also chronically suicidal at the same time.

        When bringing this up, in your case, I would strongly emphasize that you’ve never acted on these thoughts, that you don’t actually want to hurt/kill yourself, and that these are intrusive thoughts that you don’t want to have.

        Remember that for most people, a suicidal episode is a crisis-as in a brief period you can almost just wait through for things to get a bit better-and most mental health professionals will default to that model without more information. Knowing you’ve never acted on it, despite thinking about it for decades, will definitely help.

        In my case, I also made plans with my providers that if the thoughts escalated to the point where I might hurt myself, that I could promise to seek help and a plan in place to do so. I still keep a local help line number on my fridge and in my purse. That might be excessive for you, but if a provider seems especially skittish, it might help.

        As for treatments-the standard therapies are exposure-response prevention(ERPT) and cognitive behavioral therapies(CBT). I’ve never done ERPT, mostly because my thoughts aren’t quite specifically obsessive enough to work with it, but CBT has definitely helped. But for me medication has been the game changer. Without meds, I’ll think about suicide about a dozen times an hour, on a good day. With the combination we took 2 years to find, I now think about it maybe once a week and it’s not as distressing.

        And as for your Scylla, if anyone thinks that, they’re just flat out wrong. I’ve also had severe depression, anxiety and psychotic symptoms, and the intrusive suicidal thoughts are by far the worst, both in terms of feelings and functionality.

        I’d also recommend looking up suicdal obsession in OCD. You might not actually have OCD, but it’s a good model/comparison of a situation where suicidal thoughts don’t equal actually being suicidal.

        Sorry for the novel, and I’m sorry in advance if I wasn’t clear or was insensitive. Best of luck, hang in there.

        • Deiseach says:

          Sorry for the novel, and I’m sorry in advance if I wasn’t clear or was insensitive.

          No, no, this is very good advice and has indeed given me something to think about.

          In my case, I also made plans with my providers that if the thoughts escalated to the point where I might hurt myself, that I could promise to seek help and a plan in place to do so. I still keep a local help line number on my fridge and in my purse.

          The trouble there is that I would lie. I would say “Oh yes, I’ll definitely ring the helpline, thanks so much for the number” and then throw it in the bin the moment I was out the door. There’s the Samaritans helpline over here, for example, and I cannot bring myself to ring it. I absolutely cannot talk to someone on the other end of a phone line. So that’s out.

          But the thing about “intrusive thoughts” is definitely something I will think about and try and get information on, that sounds like a line I can follow. So thank you!

          • Can we be of any help? There are a lot of people here who think highly of you.

          • Orion says:

            The point is not specifically to call a hotline. The point is to think about what you would do if you had genuinely dangerous suicidal urges, before those urges arise.

          • cuke says:

            For those who hate the phone, the UK Samaritans have an email address:

            https://www.samaritans.org/how-we-can-help-you/different-ways-you-can-get-touch/what-happens-when-i-email

            I know some people in the US who have emailed them as well and gotten very kind and quick replies when there weren’t friends or family available to talk to and/or they didn’t want emergency services descending on them.

            In the US, we now have a crisis text line: https://www.crisistextline.org/

            A good therapist and/or psychiatrist ought to be able to assess and treat chronic suicidal thoughts absent plan/intent as intrusive thoughts and not as an imminent risk of self-harm. Particularly if there’s not a prior history of suicide attempts. I like what Tamar said above.

            Intrusive thoughts can be extremely distressing and debilitating. They are of a piece with OCD and anxiety and are responsive to treatment.

      • no one special says:

        At the risk of stating the obvious, have you tried an antidepressant?

        I ask because I have had the continuous background string of negative thoughts (“you’re trash. everyone hates you. the world would be better if you were dead.” etc.) and your basic $10/mo antidepressant shuts that entire thing off.

        Celexa (citalopram) 20mg: kills negative ruminations dead (for me at least.)

        • Deiseach says:

          At the risk of stating the obvious, have you tried an antidepressant?

          Would do, if I could have persuaded my doctor to prescribe me one 🙂

          Don’t know if it much helped the depression to be “so big a failure, you can’t even get a common prescription that any fool can just walk in, tell their doctor they’re depressed, and get”. Short version: went to my GP with “really worried about the suicidal thoughts, can I have an antidepressant maybe?” “are you self-harming? have you tried suicide?” “no” “oh we don’t do prescriptions any more” (literal quote there). Apparently the New Thing now is reference to counselling, which I had one (1) appointment of and went down like a lead balloon, so no counselling, no drugs, and still the same old “want to be dead but not actively killing myself” state. EDIT: Did manage to sort out for myself online sessions of CBT therapy, completed course, didn’t work for me, so no go on a recommendation for “why don’t you try CBT” either, sorry!

          EDIT EDIT: Sometimes I think being able to fake functionality is a worse thing; if I’d arrived at the doctor’s appointment as a steaming mess (that is, even more so than usual) they’d probably have gone “yeah, problem here” but turning up and being coherent, sober and not streaming blood or trying to jump out the window meant, I think, an impression of “ah just typical post-menopausal female blues, no reason to prescribe unnecessary drugs”.

          The reason I think I don’t genuinely want to be dead, just have the annoying “I wish I were dead” background thoughts, is that I’ve had a recent health scare and the reaction to that was not “great, just let it happen, I’ll be dead”. So probably never going to actually try killing myself, but really would like the goddamn “should be dead should be dead should be dead” soundtrack to shut the fuck up and don’t know how to turn it off myself.

          • Jalex says:

            It’s not very hard to buy antidepressants on the black market.

          • engleberg says:

            A really hot bath is cheap and might work. If not, it was cheap. So is whiskey, but I’d focus on the bath. Maybe another hot bath an hour later. Do some stretches in the hot bath.

          • alwhite says:

            Here are some other options that might help.

            Ozy wrote about their experience with DBT. You might be able to get something out of that.

            ACT is another type of therapy that uses pieces of CBT but also uses meditation and mindfulness to help retrain the brain.

            I would encourage you to fight for your own well being. It’s probably going to take some time to figure out and it’s going to be hard. Be committed to getting to a solution. Try to get a therapist that you can trust, even if it doesn’t seem like progress is being made. A therapist can’t give you instantaneous solutions and they can’t do the work for you, they can only be with you and assist in the work that needs to happen.

            Recruit people into your fight for wellness. When the day comes that you don’t want to do therapy (that day will come) a friend or family member can pester you back into it.

            Hopefully this doesn’t come off as too sarcastic but, remember – having a good attitude is the most important thing. :p

          • JulieK says:

            Maybe try a different doctor?
            I went to my GP, described my symptoms (lethargy, trouble concentrating, weepiness, etc.) and walked out with a prescription for escitalopram. I was surprised how easy it was.
            (And if you (generic you) have been taking the med for a month with little improvement, go back to the doctor and ask for a higher dose.)

          • SaiNushi says:

            When I was going through a rough patch, I went for therapy only, because my body has a weird chemistry that makes medications unpredictable. But my therapist mentioned that sometimes he’ll be working with someone and discover that they need medications, in which case he has a list of people to refer the patient to.

            Maybe you can find a therapist who doesn’t do medications who can recommend someone who can prescribe.

          • Nancy Lebovitz says:

            Transforming Negative Self-Talk might be useful for you– it did me some good but wasn’t a complete solution. I haven’t found a complete solution.

            The book takes an NLP approach of looking at the characteristics of the intrusive voice, and then manipulating them to make the voice weaker. It plays with making the voice softer, or giving it a silly accent, or having it come from a different direction, etc.

      • 6jfvkd8lu7cc says:

        «Try not thinking such thoughts» sounds quite inspecific…

        Although for some people (like me — but it was in a non-depressive situation, just intrusive associations/thoughts that I did not want to have) there is a way to do precisely that, which I would describe as «choose in advance some desirable thoughts to have (or topics to think about) and train self to concentrate on them whenever undesirable thoughts are noticed».

        Not sure if it works for anyone else… And it is only about thoughts, not mood or emotions.

    • Antistotle says:

      > Speaking of which, why they fuck would any sane legal system do that?

      What makes you think the legal system is “sane”?

      IMO if the legal system was a person any rational psychiatrist would involuntarily commit them.

  2. quanticle says:

    I think this is my first time commenting. If not, it’s been so long since I last commented here, I’ve forgotten. Anyway, I just wanted to say thank you for writing this. This advice would have been incredibly helpful for me when I had to deal with the inpatient psychiatric system about 10 years ago. In particular, the bit about actual stays being more like 5.9 days needs to be emphasized. When I was in, the doctors and nurses kept talking about the 3-day minimum stay. And after the three days had passed, and I was still “voluntarily” committed, no one would give me a straight answer about when I would be able to leave. It’s hard to say how psychologically wrenching it is to be trapped in conditions that are sort of prison-like (or should I say, prison-lite) without anyone giving you a straight answer on when you’ll be allowed to leave. If someone had just pulled me aside and told me, “Okay, look, I know they told you three days, but in reality it’ll be more like a week,” it would have done wonders to set my mind at ease.

    I’ve bookmarked this to share with people who are dealing with the system right now. I hope it will be as helpful to them as it would have been to me. Once again, thank you so much for writing this.

    • Scott Alexander says:

      Thanks.

      The three-day thing is a common myth, so I’ve mentioned it more explicitly in the text. I think for some states it’s actually three days, in other states it isn’t, and in other states the doctor has to file some forms within three days but realistically they’ll file the forms immediately and then keep you however long they want to keep you.

      • b_jonas says:

        You are talking about typically three days versus typically a week. But I have a question. Do weekdays versus weekends matter? Is there an effect that you’re more likely to get out on a weekday, because on a weekend there aren’t any doctors available to evaluate you?

        I’m asking this because of a particular experience when I had to stay in an uncomfortable hospital after a surgical procedure for what seemed too long for me. Part of the reason for this is that it’s more important for the doctor to monitor me to make sure that I don’t suddenly get much worse than to make me feel better in the typical case when I don’t get worse. But in the last two days, I simply couldn’t go home because the doctor needed to evaluate my condition, and he wasn’t to come in until Monday morning.

        • christmansm says:

          In the jurisdiction for our hospital, the court to challenge a 72-hour hold is only held on Wednesdays and Fridays, so the main issue is when the commitment is placed, with 72 hours being a floor. If a patient is held 73 hours before court, they can see a judge on time. If they come in on Wednesday afternoon, they could be held until the following Wednesday. So weekends sort of matter, though not the way you might think.

          That said, only a fraction of people are committed to begin with, of which only a fraction don’t get discharged relatively soon or sign in voluntary. Of those who do go to court, few are released (I’m told this varies both by state and by hospital, as our state is relatively paternalistic and our hospital relatively selective with cases.) Thus, as Scott notes, the short length of stay caused by insurance is overwhelmingly the more relevant consideration.

  3. promotoriustitiae says:

    Speaking as someone who has worked in patient advocacy in the UK for a while, this article is fairly solid for the NHS as well, with a couple of additional bits of information needed.

    1) Delete all the sections about things costing money. Every time I see posts about the US I’m very happy about the NHS.

    2) Flip side – actually obtaining treatment in the UK involves a carousel of referrals from your GP because all the mental health services are oversubscribed. The only way to avoid these is to go private, see ruinously expensive bills. There is a website for NICE which is the organisation which issues the guidelines on what hoops you need to jump through to get treatment. It’s very useful to know what steps are necessary and if your doctor doesn’t follow them then you can use that information to challenge them.

    3) In the UK then there is a mess around patient discharge – the community care responsibilities are split between the hospital, the local Clinical Commissioning Group and the local or unitary council. Obtaining a proper link up with outpatient services is highly variable and often nonexistent, you will need assistance to set this up.

    Other than that, all solid advice. Having also helped people challenge hospital decisions legally, can confirm that documentation is key. Especially unbiased witnesses. Unsurprisingly witness testimony from someone with serious psychiatric problems isn’t as helpful as, say, a stack of hospital documents with multiple independent sources.

    • Deiseach says:

      Agree with the point about money versus access. On the one hand, the US system is ruinously expensive and it’s great not to have to deal with “if I go to the doctor I will be reduced to penury”, on the other hand the whole idea of “you can just look up the phone book/online and ring up a therapist or psychiatrist to make an appointment all by yourself”, rather than the “I have to try and convince my GP that yes, I really do need to see someone about this, rather than ringing a volunteer helpline for a bit of a chat when I feel down, so I can get a referral” system here (Ireland, much the same as the UK) is some kind of fantastic wonderland of choice and accessibility 🙂

      Swings and roundabouts, I suppose!

      • Matt M says:

        it’s great not to have to deal with “if I go to the doctor I will be reduced to penury”,

        Let’s keep in mind that while “I went to the doctor and then ended up with debts that are wholly impossible to pay” is certainly a possibility in the US system, it does still seem to be the exception, rather than the norm.

        Insurance companies certainly do have an incentive not to pay out, but they still do pay out a whole lot. It sucks that the possibility exists, sure, but the picture a lot of people paint of the US health care system of “Every visit to the doctor costs $20k and insurance never pays so good luck” is not quite accurate…

        • Edward Scizorhands says:

          The hospital can bill you for a lot of money, but if you aren’t made of money, they’ll settle for a lot less rather than sue you to get blood from a stone.

          It’s incredibly stressful, yes, and needs to be addressed.

          • Matt M says:

            OK, but my point remains:

            1. Most people have insurance
            2. Most of the time, insurance covers stuff like this

            I don’t have the stats handy to quantify “most.” As I said, my only point here is to call into question the dominant narrative of “If you go to a US hospital, you leave with six figures of debt”

          • Murphy says:

            @Matt

            The endless stream of stories from americans of people doing DIY minor surgery or leaving medical problems to fester for fear of medical bills or the occasionally disturbing behavior of Americans abroad does not cover the US system in glory.

            Things like an american tourist in an accident in the UK freaking out and refusing an ambulance while bleeding heavily because he’s grown up in a system where the ambulance ride alone could wipe out his life savings and doesn’t understand that he’s currently visiting a sane country where it’s safe to accept emergency medical care you need. Stories like that also don’t cover the US system in glory.

            When you’re online and people start swapping tips for DIY dentistry… again it’s always americans, specifically poor americans. The fact that it instantly becomes trivial to guess where the users are from also does not tend to cover the US system in glory.

            indeed while “most” of the population has some kind of cover the US system is almost perfectly optimized such that the sickest people who need healthcare the most and the people most at risk of developing health problems that will need medical care are the least likely to be able to get that care.

            As in seriously: you literally have a system where some large employers have their own internal insurance such that they become incentivized to simply fire employees when they or their family members get a serious diagnosis, and many do.

            Right up until they actually need that cover the individuals are part of the majority who have cover, then the moment they need it they become part of the population who don’t have cover.

            To people who aren’t american it’s like someone sat down and tried to create a fictional healthcare system based on “how would sauron/voldemort organize this to literally maximize suffering”

          • Edward Scizorhands says:

            The endless stream of stories from americans of people doing DIY minor surgery

            Filter bubbles are amazing. Here, I have absolutely no idea what you are talking about.

          • Matt M says:

            My Twitter also includes an “endless stream” of stories from people in UK, Canada, etc. who either:

            1. Died in a hospital bed of dehydration because the nurses didn’t bother to check on them

            2. Died waiting in a multi-year queue to see some sort of specialist or receive a test that’s routine and available in days in the US

            3. Traveled to the US (or some cheaper third-world alternative) to purchase treatment that their “free” government health care denied

            I assume these stories are exceptions, rather than the norm. As are the “I went to the doctor for a hangnail and left with $200,000 in medical bills” stories that Europe loves to share about America.

          • For what the information is worth, I’ve had serious medical issues twice in the past decade or so, in neither case psychological, and both times the insurance paid the bill with no problem. It was a little bizarre reading the bill—enormous sums charged, much smaller sums paid by the insurance company, and nothing still owed.

          • gbdub says:

            indeed while “most” of the population has some kind of cover the US system is almost perfectly optimized such that the sickest people who need healthcare the most and the people most at risk of developing health problems that will need medical care are the least likely to be able to get that care.

            Y’all realize that Medicaid, i.e. medical care for poor people that covers basically everything the NHS does, exists right? It’s far from perfect but the idea that there are millions of people dying in the streets or having to choose between food and medicine is highly overblown.

            The people most screwed by the American system are the slice of people who are too rich for Medicaid, but too poor / underemployed to have decent health insurance. It’s a relatively small slice, and a lot of them probably could afford some insurance, or already qualify for benefits that they aren’t taking advantage of.

            If you’re employed and middle class (which is most people!) your out of pocket expenses are usually manageable (and many NHS fans fail to account for the chunk of their income that goes to supporting NHS as a personal cost), insurance almost always pays without any fuss, and the ability to get an MRI on your twisted ankle tomorrow instead of 3 doctor visits, 6 weeks, and 12 phone calls from now is well worth the copay.

          • Orion says:

            @gdub,

            Medicaid is pretty good, but in some states there are more requirements to get onto it than simply having no income. I live in Virginia. A couple years ago, you couldn’t get onto Medicaid unless you were raising a child or receiving disability benefits. Maybe there were a couple other ways, I don’t know. I do know that as a random 20-something allegedly-able-bodied unemployed man, I was denied.

            I have (a slightly nerfed version of) Medicaid now, because Governor McAuliffe pushed through a program that allows people with “serious mental illness” to get Medicaid even if they’re not officially disabled.

          • Nornagest says:

            The hospital can bill you for a lot of money, but if you aren’t made of money, they’ll settle for a lot less rather than sue you to get blood from a stone.

            When I was in college, one of my housemates got in a skiing accident and ended up needing a hospital stay. His parents’ insurance refused to cover it for complicated reasons I don’t remember the details of, and the hospital charged him tens of thousands of dollars.

            After a few rounds of back-and-forth mail, they settled for something like six hundred.

          • Murphy says:

            gbdub

            Y’all realize that Medicaid, i.e. medical care for poor people that covers basically everything the NHS does, exists right?

            which would be a stunning reply… if it were factually true. others have already pointed out that it’s simply false. it’s kinda worrying that you believe if true to be honest. What kind of filter bubble do you need to be in to miss a solid 10% of your countries entire population?

          • Careless says:

            gbdub: the people in the US who make just a bit more than the Medicaid max level are actually some of the best off aside from the very rich. As a 37 year old if I made just over the Medicaid cutoff I could get a $52 a month plan (after subsidies) with a $600 deductible/out of pocket cap, no copay on doctor visits or generic drugs, and a $5 specialist copay.

            Without subsidies these numbers go to a $390 premium, $7000 deductible, and $15/$30/$60 copays

            Ok, $540 a year on an $18,000 income is a lot, so maybe I’d go for a bronze plan, which is $0 a month after subisdy. Not that that plan would work for someone who needs routine visits with a psychiatrist, but not bad if you’re basically healthy.

          • Careless says:

            Unclear what 10% of the country Murphy is referring to.

          • Error says:

            As I said, my only point here is to call into question the dominant narrative of “If you go to a US hospital, you leave with six figures of debt”

            I think it might be worth distinguishing between “will leave with six figures of debt” and “might leave with six figures of debt.”

            Most people get what they need most of the time, as you say. Sometimes insurance won’t pay. Crucially, sometimes you don’t know whether it will or won’t until it’s too late. Any given medical expense *might* be ruinous. It probably won’t be, but you don’t know for sure when you have to make the call. This is not an okay position to be in.

            I once ended up with a four thousand dollar medical bill because the insurance company refused to pay on a technicality — six months after services had been rendered. At the time my annual income was around $12k.

            Today I am on arthritis medication with a monthly retail price that is theoretically greater than my net income. For a long time I was terrified that a similar incident could drive me into bankruptcy at any time. It never actually did, but the worry is still a nontrivial hit on one’s quality of life.

            (I eventually found out that, for this sort of medication, they won’t even accept the order until after the insurance company pays. Lowered my blood pressure a good bit when someone told me that.)

        • Mary says:

          Even in the US, remember, most of the debt associated with illness stems from lost income, not medical bills.

          The studies that claim that most bankruptcies are medical do so by claiming any small medical bill makes the whole shebang medical, or which the bankrupt person describes as medical — and also on a biased group, since people voluntarily choose to respond.

          • b_jonas says:

            > Even in the US, remember, most of the debt associated with illness stems from lost income, not medical bills.

            Yes, and as a European I also hear scary stories from the U. S. about that side too. Stories about how employees have to work even when they’re really sick, because if they call in and miss their work when they’re really ill and in a hospital, they get fired immediately.

          • Evan Þ says:

            @b_jonas, unsurprisingly, that varies a lot with the employer. Several years ago, I had a coworker who had a seizure at work to everyone’s surprise; an ambulance showed up and brought him to the hospital for several weeks, and there was absolutely no problem.

            Also, we have the Family and Medical Leave Act which, for companies over 50 people and employees who’ve worked there at least a year, gives you twelve weeks of unpaid medical leave per year. It’s unpaid, but your job’s secure when you get better.

          • antpocalypse says:

            @Evan: The conditions on the FMLA (employees also have to have worked 1250 hours in the last 12 months, so half-time positions are fair game) make it seem like a practically worthless gesture. Certainly it would be worse not to have it, but it really only protects against the most cartoonishly evil behavior, and even then not for all workers.

          • tlwest says:

            Indeed, I was surprised to find that health-related bankruptcies were not all that different between Canada and the US for exactly this reason

            On the other hand, I’d never, ever trade the Canadian system for the shambolic horror that’s the American system. Outside of the very wealthy, the health outcomes are almost indistinguishable, except the American system is 3 times the cost and about 10 times the personal insecurity.

          • The Nybbler says:

            What would happen to Canadian healthcare outcomes if the US switched to a rationing-by-waiting system and thus the safety valve ofcoming to the US for treatment wasn’t available any more?

          • Matt M says:

            On the other hand, I’d never, ever trade the Canadian system for the shambolic horror that’s the American system.

            See, this is the kind of stuff that annoys me.

            The entire reason I brought this up in the first place was to counter this sort of hyperbole. The US health care system works very well for most people. Calling it a “shambolic horror” is absurd. Even before Obamacare, upwards of 80% of Americans had insurance, and over 80% of those were satisfied with their insurance.

            This is exactly why Obama made such a big deal out of the whole “If you like your insurance, you can keep it” messaging, (which later won “lie of the year” from left-leaning politifact). People were very upset that increased state involvement in healthcare led to a loss of choice, and vastly increased prices on something they had been buying consistently for years.

            If something is a “shambolic horror” your messaging should probably be “I will radically change this thing you hate,” rather than “Don’t worry, I’m not going to change anything for you.”

        • cuke says:

          Looks like just over 12% of U.S. adults have no health insurance. Nearly 40% of U.S. adults have high deductible plans, including through their full-time employers.

          This means many people who live paycheck to paycheck cannot afford to access healthcare despite having health insurance. They don’t see doctors or go to hospitals or get mental healthcare when it’s medically necessary for them. If they have a medical emergency, they may be in debt for the full $6-12,000 deductible with no way to pay it back.

          I don’t know at what point we call it a norm, but it looks to me like 52% of U.S. adults are one health emergency away from potentially crippling medical debt. Maybe a health economist could weigh in to clarify this better.

          • Evan Þ says:

            I have a high-deductible health plan, and I love it. My employer, a Very Large Software Company, gave me the choice of a more traditional plan, or a high-deductible where they put a small amount of money in my health savings account each year. Most years, I see the doctor maybe once and spend less than that small amount, so choosing the traditional plan would basically be passing up money.

            Now, I’ve got over $12,000 in my HSA. If I need to spend it all, it’s there. Otherwise, it’s growing tax free till retirement.

            I’m sure the 40% of American adults with high-deductible plans includes a number who aren’t in as good a situation as me – but I’m sure it also includes a number who are.

          • Matt M says:

            High-deductible plans are also great from a libertarian policy perspective.

            To the extent that one believes the high prices for routine care in the US system are largely the result of perverse incentive systems, where the payer and the recipient are entirely different people with entirely different incentives – high deductible plans restore some sense of reasonable market incentives. Consider that if everyone had an infinitely high deductible, that would be, in effect, a free market in medicine.

            The more people we get on high-deductible plans who are therefore now suddenly incentivized to care about prices, to demand transparency, to shop around, etc. the more medical providers themselves will suddenly find the need to price appropriately.

      • christhenottopher says:

        It’s worth noting that US out of pocket spending on healthcare is a lower percent of consumption than the OECD average (and lower than Ireland). It’s also lower than average as percentage of total health care expenditure. Extremes can and do happen in the US, possibly more than extremes in other countries, but they are not typical experiences here. And worth noting on the “does not cost money in the NHS” thing, the UK does have lower out of pocket spending than the US and these particular procedures might be covered, but out of pocket costs in health care are clearly not zero.

        • Murphy says:

          Ah, sorry, but that’s utter BS and you’ve been taken in my an oft-repeated con.

          (I’m taking the necessary and true defense here)

          If you follow the references you’ll find they exclude regular insurance premiums from the US numbers. They bury it in a footnote in one of the references. (thought I’m also getting some dead links right now)

          I’ve come across this claim before with the same supporting data but whoever fed you that link is getting extra-dishonest. They used to link directly to the document with the footnote.

          So if you pay 15K per year in premiums and 7 K per year on top of that in co-pays and non-covered fees etc they mark it as 7K, not 22K. because the 15 K is your insurance payments, not healthcare spending.

          It’s bullshit. Intentionally crafted to mislead you.

          For total spending here’s a more representative chart of spending as share of GDP:

          https://theincidentaleconomist.com/wordpress/wp-content/uploads/2011/09/oecd-pub-pri.png

          Hint: for private spending, insurance companies aren’t in the habit of handing out more cash than they take in. For out-of-pocket spending to be so low the companies would need to be losing vast sums every year.

          • christhenottopher says:

            I know that US spending is higher yes, everyone does. But the hospital bills people talk about being destructive towards one’s finances are destructive when they are out of pocket not through the mechanism of government spending or insurance premiums, which is what this particular discussion was about. If you want “why is the US so expensive” and you really want to do a deep dive into the numbers, it’s because health care is a superior good who’s cost rises non-linearly with consumption levels rather than the specifics of how we pay for health care.

            So yes, more private spending occurs and more total spending occurs, but when a hospital bill comes in, whether the spending is private or public does not impact your pocket book more, it’s the out of pocket that matters. And framing this as conservative vs left wing, while true in most settings, is not really that helpful for discussion or determining truth.

            And if it means anything, I agree your statement is true, less necessary than you think, but still the necessity is debatable enough to pass in my book. Not even as unkind as I’ve seen on the internet so I’d give you a pass there too personally.

          • If you follow the references you’ll find they exclude regular insurance premiums from the US numbers.

            They also exclude the taxes that you pay in the U.K. in order to finance the NHS. The article is perfectly clear–what it is measuring is the out of pocket payment, what isn’t covered by either private or public insurance.

            You wrote:

            The endless stream of stories from americans of people doing DIY minor surgery or leaving medical problems to fester for fear of medical bills

            That’s not a claim about people having to spend too much on health insurance, it’s a claim about people either not having health insurance and so having to pay for medical care they get out of pocket or people having health insurance that refuses to pay for their care. Both of which would result in out of pocket expenditures.

            The high cost of medical care in the U.S. is a serious issue, but it isn’t the issue you raised.

            whoever fed you that link is getting extra-dishonest. They used to link directly to the document with the footnote.

            The link goes to an article which starts:

            Financial protection through public or private health insurance substantially reduces the amount that people pay directly for medical care, yet in some countries the burden of out-of-pocket spending can still create barriers to health care access and use.

            What part of “private and public health insurance” did you have difficulty understanding?

          • Murphy says:

            Financial protection through public or private health insurance substantially reduces the amount that people pay directly for medical care, yet in some countries the burden of out-of-pocket spending can still create barriers to health care access and use.

            What part of “private and public health insurance” did you have difficulty understanding?

            Well for one the phrasing of “reducing” through private health insurance doesn’t imply they removed that reduced amount entirely from the graph.

            Try this test, show the graph to a handful of conservative first year students already primed to believe that the american system is super in every way. Ask them if the graph from that phrasing whether “out of pocket” excludes non-mandatory health insurance premiums without showing them the honest graphs first.

            most people parse “out of pocket” as cost post-tax. Unsurprisingly 99% of the time that link gets shared that’s the position taken by whatever youngen has been taken in by the con.

            “Honest” does not mean “uses weasel words so as to avoid directly stating flat out lies” indeed, most would traditionally categorise that under the term “dishonest”

            The comparison does not benefit from including taxes to finance the NHS since the US already spends as much per citizen.

            you should already have your own version of the NHS for what you’re paying but somehow the US manages to pay twice as much while still leaving a large fraction of it’s citizens screwed.

          • The Nybbler says:

            most people parse “out of pocket” as cost post-tax. Unsurprisingly 99% of the time that link gets shared that’s the position taken by whatever youngen has been taken in by the con.

            Health insurance premiums paid through ones employer as a paycheck deduction are pre-tax. Health insurance premiums paid by the self-employed are pre-tax (tax deductible). So there’s no problem here.

          • Murphy says:

            Paying your babysitter can be tax deductible in certain very limited circumstances but any claim based on that to claim it’s not “out of pocket” would be absurd.

            Ditto for insurance premiums.

          • The Nybbler says:

            @Murphy

            I used your definition. If you didn’t like it, you shouldn’t have proposed it.

            If you meant that “out of pocket” excludes taxes but includes regular payments to private entities, you’re just obviously putting your thumb on the scale.

          • Doctor Mist says:

            [Deleted; I made a snarky comment that didn’t actually add to the discussion.]

          • Financial protection through public or private health insurance substantially reduces the amount that people pay directly for medical care, yet in some countries the burden of out-of-pocket spending can still create barriers to health care access and use.

            What part of “private and public health insurance” did you have difficulty understanding?

            Well for one the phrasing of “reducing” through private health insurance doesn’t imply they removed that reduced amount entirely from the graph.

            If they didn’t remove any of it the statement would make no sense, and if coverage by private insurance reduces out-of-pocket expenditure that obviously implies that the cost of private insurance is not being included in out-of-pocket expenditure.

            “Honest” does not mean “uses weasel words so as to avoid directly stating flat out lies” indeed, most would traditionally categorise that under the term “dishonest”

            There are no weasel words there. The passage distinguishes out-of-pocket expenditures from what is covered by private and public insurance.

            I am tempted to respond that complaining that people are being dishonest because you are able, with a great deal of effort, to misread a plaint text is itself dishonest, but my guess is that you really believe what you are writing so that would not be an accurate description.

            The comparison does not benefit from including taxes to finance the NHS since the US already spends as much per citizen.

            We both agree that U.S. healthcare is anomalously expensive. But the original discussion, coming out of your comment, was about people who faced large bills that were not covered by insurance, not about insurance being expensive, so the quote on out-of-pocket costs was entirely appropriate.

            Given that the quote lumped together private and public insurance, to do the calculation in the way you implied it should be done, including the cost of private but not public insurance, would have been dishonest, and the fact that that was not obvious to you ought to bother you.

      • Tracy W says:

        In my experience in NZ and the UK, going private, while expensive, is not expensive on the level of the USA. I have health insurance for operations (there’s a long waiting list for non-emergency surgeries) and a few other incredibly expensive things and I just pay for the rest out of pocket.

        • johan_larson says:

          US fees tend to be inflated, because they are the pre-insurance rates and hospitals know insurance companies demand and can get hefty discounts. The fees that actually get paid are dramatically lower.

          Apparently it is possible to negotiate the fees down post-facto, even as an individual, but it’s time-consuming and intimidating.

          • Mary says:

            If you can pay immediately, I hear the magic words are to ask whether there’s a discount for that.

          • Not always time-consuming and not always after the fact…I negotiated the cost of a dental crown in about 5 minutes. Cut the cost in half provided I paid cash, and the dental practice was perfectly happy with that outcome. (Which told me something about what fraction of those theoretical bills to insurers they actually collect.) Several years later that crown is still in place and doing fine.

            Also did an accidental negotiation once. While departing a pediatrician’s office I was handed the bill, and grumbled out loud about what seemed like a ridiculous amount to x-ray a child’s limb. Happened to sigh about not submitting it to our insurance due to annual deductible or somesuch, and the doctor literally snatched the bill out of my hand. “Oh, sorry, this isn’t for insurance? One sec.” She took a pen and lined through it right in front of me and cut the amount due in half, and handed it back to the admin person to adjust and print out afresh. Completely casual, this was clearly a normal adjustment. “Have a nice day!”

        • alef says:

          Serious question…

          If I have a net worth of $1.5M (home equity in a Western-but-not-California state, 20 years retirement savings, other assets) and I’m charged $250k all up to handle my stroke, how do I negotiate these savings. As it is, my insurance company paid $13k to clear this $250k bill, super negotiators! But suppose I have no insurance.
          What do I say to clear this for 13k (or 26k or 52k or anything in the ballpark?) Or is it really going to cost me $250k – if I have assets above that but no insurance?

          • johan_larson says:

            If you are facing a bill that large, your best bet is probably to hire some professional help. There are medical bill negotiation services out there, such as this one:

            http://medicalbillmediation.com/

          • Murphy says:

            @johan_larson

            Your credit card* is charged a $500 deposit (which is non-refundable if unable to negotiate bills).

            Wow, $500 just to get started with absolutely no guarantee of any kind that they’ll do anything. They do not appear to be lawyers or any kind of regulated profession so no professional standards body to worry about.

            So it looks like I could set up a site like that, bill $500 a pop, whenever someone pays I take the details they fill in, make one phone call to say “hey, will you reduce John Smiths bill pretty please”, if they say “no” I laugh, documents that “I tried but was unable to negotiate bills“. in the unlikely event that they say “ok, we’ll take 15K off that bill of 250K” I can now charge the individual $3500.

            On the off-chance that the already financially crippled people try to sue me, well, I fulfilled everything guaranteed on the site and can show that I contacted the creditor and “tried”.

            I mean wow. There is literally no way for me to lose as long as I half-arse it and don’t do something silly like invest serious time into it. either I get free money or I get even more free money for 1 phone call.

            it’s beautiful.

    • John Schilling says:

      1) Delete all the sections about things costing money. Every time I see posts about the US I’m very happy about the NHS.

      Followed immediately by:

      2) Flip side – actually obtaining treatment in the UK involves a carousel of referrals from your GP because all the mental health services are oversubscribed. The only way to avoid these is to go private, see ruinously expensive bills.

      So much for deleting the section about things costing money. Fortunately, extreme cognitive dissonance is not on the list of things that call for involuntary commitment.

      • Randy M says:

        I think to be charitable he was acknowledging the trade off but still coming down on the UK side, rather than cognitive dissonance.

        • gbdub says:

          Strongly preferring “it’s free, but you can’t have it” to “you can have it, but you can’t afford it” is at least a little bit dissonant.

          Well, really, for most people it’s more like “it’s free, but you can’t have it for awhile and you’ll need to spend a bunch of time and jumping through a bunch of hoops getting it arranged, hope you have your shit together and your boss doesn’t mind” vs. “we can see you Thursday, that will be $200”.

          The requirement to have your shit together to jump through the hoops might be a reason to not prefer the UK system, at least for the specific case of mental health care. The mentally ill aren’t particularly known for their organizational skills.

          • Matt M says:

            The requirement to have your shit together to jump through the hoops might be a reason to not prefer the UK system, at least for the specific case of mental health care. The mentally ill aren’t particularly known for their organizational skills.

            Well, they aren’t generally known for their vast personal riches, either.

            And navigating the US health insurance system definitely requires some degree of “having your shit together” as well.

            A lot of the “I went in for some minor thing and left with an unbelievably large bill” stories boil down to people not understanding their own insurance plans, not asking the right questions, etc.

          • alef says:

            “Strongly preferring … is at least a little bit dissonant”.

            IMO it’s absurd to suggest that this is a relevant criticism of @promotoriustitiae’s contribution. Neither the ‘strongly preferring’ nor the body of the “…” is a remotely reasonable, honestly arguable, accusation.

            Yes, (s)he made an inflammatory (really?!) aside (“Every time I see posts about the US I’m very happy about the NHS.”) in an otherwise seemingly useful, seemingly factual, comment on how to modify Scott’s writing to apply help patients in the U.K.. So: because of that he is entirely maligned and distorted (and let’s now joke about whether he should be involuntarily committed for his imagined inconsistency!) because maybe, just maybe, one can twist his comments to be participation in the US healthcare ‘culture war’ ?!?

            (This group is supposed to be better than this!)

          • Murphy says:

            There’s also the choice of a hybrid system not availible to you in the US… because, well, the special magical touch of the US healthcare system which screws everything up.

            If you really really don’t trust the NHS and want that kind of instant access with no need to go to your GP to be referred to a specialist….. you still have all the freedom granted under the US system whereby you can just buy private medical insurance.

            and the tax bill for medical care is even equal, the NHS just has it’s shit together by comparison.

            Now, at this point someone who thinks they’ve spotted a flaw is about to should “AH HA! but then you have to pay for both!”. Sure. If you choose to. But the bonus when you have a decent public system to fall back on is that private medical insurance in the UK costs about 1/10th what equivalent cover would cost in the US because if you’ve got really serious problems your private provider will refer you through to the same specialists.

            So currently you’re already paying as much in taxes and getting squat while paying the same again on top of that.

            In the UK you get covered for everything and if you want to buy the one and only lonely little advantage that the US system has… it costs 1/10th the price.

            So, in the UK person without insurance is left universally better off than person without insurance in the US.

            A UK person with insurance is left with far more of their income left in their pockets and still ends up universally better off than their equivalent in the US…. even if something happens like their insurance company company messing them around or goes bankrupt. The NHS has still got their back.

            if you like choice , freedom and value for money. if you value any of those the NHS scores better.

            It takes some serious cognitive dissonance to look at that and say “I’ll take the more expensive worse option with the same tax burden please because it’s better!”

        • alef says:

          I don’t think even that much charity is needed.

          @promotoriustitiae is not debating health care systems in the abstract; (s)he is describing three changes to what Scott wrote that would make it more relevant and correct for a UK patient.

          Step 1 is surely best as to suggest we delete all those sections in Scott’s writings about patent costs and financial risks (probably correctly so; in the UK these sections are basically wrong.) Then two paragraphs later, he suggests adding something that does warn of large (maybe ruinous) UK costs. That seems helpful, and someone balanced if you want to make it political, but where’s the contradiction? I suppose could read section 1 saying that nothing at all about costs belongs in any UK version of the document, but even if you read it this way at first, why would you maintain such an uncharitable reading after it’s blatantly contradicted shortly thereafter.

          • promotoriustitiae says:

            Pretty much what alef said – you can pay for treatment in the UK but it’s ruinously expensive… *compared to the NHS*. In a US context it’s all pretty affordable and you can get decent and fast treatment if you’re willing to shell out a little. There are private clinics which will give you appointments today for whatever you want.

            As for the actual state of UK mental health services then it’s pretty good. The role of the GPs as gatekeepers is a curious one which bears close examination for people who want to know how you get an efficient system. The main delays come in very specialised areas or in a couple of pressure points. The issue with being an advocate is that you mostly see those pressure points and areas.

            To give a concrete example of a pressure point, lots of people want individual talking therapy. There’s plenty of good evidence for it working for them (that I have been pointed to at least) and they want it but… it’s more expensive than antidepressants and there’s not enough services to go round. NICE have made the trade-offs and put some barriers in the way to separate out the people who benefit most. So most people end up in group settings which aren’t exactly for them or on drugs which have side-effects. Then if none of that works, maybe they get what they wanted in the first place.

            As for how to solve those problems, well, if we threw the same percentage of GDP as the US does at the problem it would be a heck of a lot smaller. There’s also broader issues from that like the training/recruitment pathways for specialists and the ethics of just buying doctors and nurses from other countries that don’t have the funds to throw.

            I note for the general rationalist community, NICE is an interesting example of an organisation explicitly built for maximising patient outcomes given a specific input of resources and evidence. If you’re in favour of utilitarianism but don’t like NICE and its consequences, you should examine your principles.

          • meltedcheesefondue says:

            I’ve always approved of NICE.

          • Am I the only one here who sees NICE and immediately thinks of the bad guys in That Hideous Strength?

          • Nancy Lebovitz says:

            No.

  4. engleberg says:

    @Actually hiring a lawyer will definitely get people’s attention .. . I would feel bad if someone hired a lawyer and after a huge legal bill it did no good-

    A while back I hired a lawyer to write a letter with something legal on the letterhead. The lawyer took my 80$, made a three minute phone call that started with him mentioning he was a lawyer, and my problem went away. Strongly recommend this to anyone hassled by an organization that just isn’t listening to your side at all.

    • russellsteapot42 says:

      “Hi, Mr. Lawyer? How much do you charge per hour, and what is the smallest interval of time you are willing to charge for?”

      • engleberg says:

        Yes, you bet I stressed I just wanted one simple thing and what is the price in advance. Not a magic bullet, but well worth about a hundred bucks, sometimes.

  5. nameless1 says:

    One time my mother got psychotic, seeing ghosts and writing on the wall. Previous to that, she was vomiting for three days straight due to eating bad food. She was put in a psychiatric hospital, stuffed full of drugs that made her a sleepy zombie (I think instead of expensive antipsychotics they basically just knocked her out with something like Xanax) and things did not improve. Meanwhile my father talked to an experienced family doctor who asked him what happened in the recent days and when my father mentioned the vomiting the doctor figured the cause must be dehydration. As my mother was too knocked out to bother about drinking in the hospital, he had to yell at them until they IV’d her some water. She got well rapidly. BTW it was in Europe.

    The moral of the story is that there are a few things you can check yourself if a family member starts acting weird and dehydration is one of them.

    Another thing is that if any family member, who is acting or feeling weird, gets blood work done for any reason, related or not, look at it and ask the doctors about anything that is clearly outside the reference range. Sometimes they just simply don’t notice the magnesium deficiency or realize that is the reason for the problems of the patient.

  6. poignardazur says:

    Okay, I know that this is probably mostly me being sheltered from medical institutions, and unaware of how bad psychosis can get… but some of your advice seems really, REALLY unethical, and not just in a “it would be illegal for me to recommend it as a doctor” way.

    Especially the last sections, with advice on how to get the nice men in white jackets to give your nephew his injection he actively doesn’t want every six months, or how if all else fails and the law isn’t on your side you can always splice his marijuana under false pretenses (admittedly with a different kind of marijuana and not just mystery drugs, but still). What the fuck?

    • Doug says:

      None of this constituted advice. In fact Scott explicitly said it wasn’t advice. All I see is a simple, straight-forward recording of facts. The accepted gold standard for psychosis *is* long-acting injectables. Cannabidiol *does* act as an antipsychotic. You can do with that information what you want, but can it be unethical to simply tell the truth?

      Most of the time, liberal Westerners accept that accurate public information is good. Even if that information may potentially be used by unethical actors. It’s better for everyone to know the truth. Trying to censor unpleasant facts just leads to a situation where unscrupulous conmen can dish out self-serving lies because the public loses trust in the authorities. It’s telling kids that they can get pregnant from oral sex, or that they can die from a marijuana overdose. It’s discovering a major security flaw in Windows, and just burying it, instead of alerting the public.

      For some reason, most people think that medical information is special in some way. Plebeians without an MD couldn’t possibly be trusted with their genome or blood chemistry. They will just go out and do something dumb and irrational. In fact don’t even let them hear about any new findings that they might misinterpret, like moderate alcohol consumption’s health benefits. That will just make people go out and drink a six-pack everyday. Medical knowledge is special, and sacrosanct, and can only be safely handled by the priestly caste with the white coats.

      SSC readers are one of the most mature, rational and intelligent communities on the Internet. If they can’t handle the unfettered “truth”, then I doubt anyone can. Sure a hundred years ago some hucksters made a mint selling snake oil to treat arthritis. And Steve Jobs though acupuncture could cure cancer. But I don’t see why that justifies that the foundational liberal ethic of free and open information ends where medicine begins.

      • Not A Random Name says:

        Not sure if trolling but:

        You can do with that information what you want, but can it be unethical to simply tell the truth?

        I mean, subjective morality and all that. But for the vast majority of people the answer to this question is a resounding: Yes, of course.

        If you get someone innocent hurt or killed by simply telling the truth when you didn’t need to and could’ve just lied and prevented it – well, most people think that’s pretty unethical.

        • Doug says:

          The only exceptions I see are breach of fiduciary duty or outright theft (i.e. a doctor divulging his patient’s private medical info, or the hacking of military secrets). Outside that, I don’t think most people would consider telling the truth unethical. In fact most traditional moral systems have fairly strict prohibitions against lying. And none that I know of make a utilitarian exception.

          Also, I know legality is not as strong a condition as ethicalness, but Western legal systems pretty much accept truth as an unconditional defense. (Again with the exception of breach of fiduciary duty.)

          Do you have any specific scenarios in mind? Besides some sort of trolley car problem that strains the limits of all of deontology?

          • Jiro says:

            “If you go to that bar at 3 AM whn it’s closing and wait across the street with a sniper rifle you can kill as many Ruritanians as you want with little risk to yourself” may be a true statement, but I would normally consider it unethical to say anyway, and so would most traditional moral systems.

          • Doug says:

            @Jiro

            I don’t understand the analogy. Could you explain?

          • moscanarius says:

            Doug, I think Jiro means that sharing this info can lead Ruritanians being killed, because there is always a chance that whoever you’re telling it might be willing to kill Ruritanians, or at least might innocently spread the info until it reaches someone who wants to kill Ruritanians.

            I would pose something more simple: a bunch of scary-looking thugs arrive at the bar and say “We hate Ruritanians, do you know if the guy on the corner is a Ruritanian?”. Is it ethical to tell them the truth that, indeed, that guy is a Ruritanian? Most people would say no, as telling the truth may bring a great, preventable harm. There you have a scenario where spreading the truth is not ethical.

          • jumpinjacksplash says:

            Or, the classic:

            It’s night-time. You see a panicked-looking young woman running past you with her clothes torn. A few minutes later, a man with a balaclava covered in blood and holding a knife sprints over front the same direction and asks, “Where did she go?” Should you tell him the truth?

          • Nancy Lebovitz says:

            It’s not quite that simple about truth as a defence in British libel law.

            https://en.wikipedia.org/wiki/English_defamation_law

          • Not A Random Name says:

            The bible says you shouldn’t lie but every Christian I know personally thinks the people hiding Jews during WW2 were doing the right thing, even though it’s understood that probably meant lying somewhere down the line.

            Another example is truths that are just unnecessary and uncalled for. Simple things like thinking “my coworker really is an idiot sometimes” might be true yet still basically nobody will accept “But it’s the truth!” as a valid excuse for telling them over and over.

            And even traditional moral systems that generally value the truth and don’t allow lying come to the same conclusion: “It’s the truth” is a necessary but not a sufficient condition for what you say to be ethical in this context.

          • Randy M says:

            I think generally “don’t lie” assumes good faith actors. It’s reasonable to consider whether the rules for behavior in one’s personal, professional, and civil life are the same as the rules for dealing with a homicidal knife-wielding maniac. Given one is allowed to kill in defense of self or others, taking license with the truth is likely allowed.
            As to broadcasting sincere appraisals of other people’s characteristics, one should consider the stance on gossip.

          • Nancy Lebovitz says:

            Does the Bible actually say not to lie? There’s a commandment against bearing false witness, but that’s much more limited than a rule against all lying.

          • John Schilling says:

            There are things like Proverbs 12:22,

            “Lying lips are an abomination to the Lord, but those who act faithfully are his delight”

            But Proverbs are more like guidelines anyway, and you’re right that the actual commandment is to not falsely accuse people. So are a lot of the secondary references to dishonesty. I don’t think you can get strong Biblical support for “all statements must be 100% truthful no exceptions”.

    • holomanga says:

      A good example of this would be them threatening to hurt you, or actually hurting you, or being so out of touch with reality that you are legitimately afraid they might hurt you or themselves.

      If they’re just an ordinary psychotic person, then when you call the police or drive them to a hospital or something they go “sorry sir, I think there’s been a misunderstanding :)” and the other guy goes “no worries, have a nice day :)” and then they go back to their apartment where they go and think that the world’s a simulation in peace and maybe stop answering your calls because you just called the police on them, which is kind of a dick move.

      This stuff only happens in the edge cases where no matter what you pick there’ll be a lot of people finding it unethical and coercive.

    • Deiseach says:

      Especially the last sections, with advice on how to get the nice men in white jackets to give your nephew his injection he actively doesn’t want every six months

      This is the problem, isn’t it? Do you leave your nephew alone to roll naked in dogshit and wander into traffic in the middle of the road (real-life example I’ve heard of) because he doesn’t want to take the medication that makes him not wander into traffic, thus respecting his choice to get himself killed messily and traumatise the poor devil whose car ran into him, or do you act underhanded and not respect his stated choice and force him to take the drugs?

      It’s not an easy dilemma: for every overblown Hollywood (and indie film maker) movie about horrific abuse in the loony bin of free-spirited creative eccentrics who only want to wander barefoot through flower meadows and make love and art instead of joining the capitalist rat-race, there are people really rolling in dog shit and getting themselves killed, or killing family members and friends. And for every Hollywood slasher movie about the psycho with the knife, there are people really being treated badly by an indifferent system that stuffs them full of drugs with terrible side-effects.

      In a previous job, I saw the experience of dealing with paranoid schizophrenics off their meds. It was not good for them. It wrecked their lives and the lives of the family dependent on them. Respecting a choice for X to not take their meds means Y, who is X’s minor child, is put in a shitty position living with a literally crazy parent even if X is not physically harmful to them (in the sense of trying to stab them; having X destroy the kitchen because they think the neighbours are listening in on them through the walls doesn’t help with the ‘cook and eat healthy nutritious meals’ part of growing up).

      I don’t want people strapped down to beds with drugs forced into them. But it’s not as easy as “let Nephew Larry do his own thing”, either.

      • poignardazur says:

        Yeah, I guess I can’t claim to be an utilitarianist and then say that consent is more important than anything.

        That said, leaving aside the trees and looking at the metaphorical forest, would you say you agree with section 12, on average?

        That’s an honest question; what Scott said about messing with someone’s drugs seems really shitty to me (if probably harmless in that specific case); but I have no experience with mental illness, so maybe what you mention about how vital meds can be outweighs the importance of the “don’t ever spike someone else’s drink / meds / drugs” general principle.

        • moscanarius says:

          But respecting their consent in this instance can eventually lead to having to disrespect their consent latter in much worse terms. If the paranoid guy eventually tries to choke his wife or his neighbour, he will land in jail (very much in spite of his consent). If he breaks into someone’s house he may get beaten or shot, again very much against his wishes. If this could be avoided by disrespecting his ability to consent, does disrespecting it still sounds wrong to you?

        • Freddie deBoer says:

          Where does he say to deceive them into taking those drugs? That literally does not appear in that section.

        • notpeerreviewed says:

          I’m pretty sure “wrangle” in this context means “use every trick in the book, especially extreme persistence, to get them to consent”, not “trick them into taking a drug without their consent.”

        • russellsteapot42 says:

          It seeming shitty to you is a part of your general ethical heuristic, because there are very few situations that justify that kind of action, and many more situations where someone would take that kind of action maliciously.

          Doing ethical calculus is hard, so your mind simplifies this to ‘this is really shitty’ and you’ll generally only be able to override that when the reality of the situation is significantly shittier than that. And that’s not something you’ll be easily able to get a sense of when we’re talking about hypotheticals on paper in dry terms.

          • IvanFyodorovich says:

            “there are very few situations that justify that kind of action, and many more situations where someone would take that kind of action maliciously.”

            Russell, you seem to be claiming that severe psychosis is very rare whereas wanting to maliciously dose your relatives with antipsychotics is common. That seems extremely unlikely.

        • antpocalypse says:

          Unless the section has been edited since publication (and I’m pretty sure I read this post before there were any comments, so I don’t think it has been), I don’t think it reads as suggesting you should adulterate their drugs without their knowledge. It sounds more like suggesting that you say, “Hey, I’ve heard high-CBD weed can help with anxiety/pain/whatever without getting you super high, so I ran by the dispensary for you” and keep the addendum about psychosis to yourself.

    • adrusi says:

      I don’t actually think Scott suggested offering someone marijuana and then giving them FAKE-WEIRD-CANNABIDIOL marijuana instead of what they expect. First of all that would be impossible to pull off, because people expect marijuana to get them high, and cannabidiol does not get you high. Second, ordinary THC-rich marijuana isn’t really something one should expect if they’re offered marijuana to help with their anxiety, as THC is more likely to cause anxiety than to treat it.

      • Freddie deBoer says:

        Yeah there’s no suggestion of subterfuge at all, it’s just saying “here’s something that might work that you can (maybe) get without a prescription.”

  7. Tracy W says:

    there may not be much in the way of entertainment, quiet, or privacy

    Totally true, particularly the quiet. I was recently in a small ER in New Zealand, and even they were well-stocked with “the machines that go bing”! It was an unpleasant shock I can’t imagine how many binging and beeping machines an American ER has.

  8. Enkidum says:

    Most people who take hallucinogenic drugs will hallucinate.

    Is this true? Because I’ve taken quite a few, and I’ve never had anything that most people would consider a bonafide hallucination. There’s frequently stuff just outside the fovea that’s a little messed up (lines between tiles disappearing, for example), and kind of shifting translucent textures on things, but nothing along the lines of perceiving an object or animal that isn’t actually there. And the large majority of people who I know that have taken hallucinogens, when pressed, will admit that this is true of them as well.

    • Doug says:

      Mostly true, but I think you’re confounding hallucinogen with psychedelics. Which are just one sub-type of hallucinogens. Salvia will definitely cause all-encompassing hallucinogens. To the point where the user *only* perceives objects that don’t exist. Most classical NMDA dissociatives will cause hallucinogens at high enough doses. Dissociatives in combination with psychedelics will frequently cause the perception of one object as a totally different object (like thinking a television is a fireplace). Even at moderate dosages. Deleriants by definition will cause true hallucinations at any psychoactive dose.

      Finally even among psychedelics, high dosages of certain drugs will cause true hallucinations. Particularly DMT or LSD. This isn’t so much a qualitatively different phenomenon than the “breathing walls”, but how the brain responds when that effect gets amped up. Once the shifting becomes intense enough, there’s a phase change in the top-down cognitive processing. The brain will accept that an inanimate object slowly shifting is still X, particularly given strong priors. But if it becomes too distorted, the top-down processor will discard the interpretation of X as X and start looking for other objects that it could be. Kind of like the optical illusion with two faces and a vase.

    • Nornagest says:

      The medical sense of “hallucination” is a lot looser than the colloquial one. You’d have to get exceptionally high for your dog to start talking to you, but researchers would call your experiences hallucinations long before that point.

  9. johan_larson says:

    The part of all of this that makes me uneasy from a libertarian perspective is that it’s ok to lock someone up for thinking about killing himself and saying so. Harming others? Sure. Thinking about harming others? Well, I suppose. Flat-out delusional? Ok. But if the only person you might be a danger to is yourself, then I don’t see that force is justified, even by the most highly qualified and well-intentioned among us.

    • userfriendlyyy says:

      Well, the problem with that train of thought is that it assumes suicide could be a rational decision which is something our religious, moralistic society will never accept. You’d have to go to Belgium to have your right to die respected.

    • jasmith79 says:

      You’re missing the point. We’re not talking about denying a competent actor their choices. Would you say that an 6 year old child should be allowed to do anything they wished? Why not? Same logic applies. Of course, how do we determine competence? It’s not always as clear cut as it is with the 6 year old. Teenagers? Mentally-handicapped adults? Suicidal? So I understand the temptation to sweep it under the rug of free choice. But suicide is frequently an act of impulse, and a fair number of people with unsuccessful suicide attempts do not go on to have successful ones, or get better on medication (i.e. suicide was not their actual revealed preference). If I got drunk/high and decided I wanted to jump off a 5 meter drop “because it looked fun” wouldn’t you try to stop me (if that ever happens please stop me)?

      • russellsteapot42 says:

        It’s apparently a not-uncommon experience for suicidal people to talk about having regretted attempting suicide just after they’ve physically committed to it.

        • Mary says:

          It’s not uncommon for the 911 call that gets the people there in time to save the life to come from the person who made the attempt.

    • Murphy says:

      I get your point, I don’t feel fully comfortable with the fact that suicidality alone can be taken as proof of lack of competence. (after all, there are some quite reasonable reasons to want to stop living sometimes)

      But it’s not based on libertarian philosophy.

      If someone wants to cut open their arteries because they’re convinced they’re full of spiders or is someone wants to cut open their veins because they’ve developed an overwhelming preference for dying both tick the Danger To Self box and those with a duty of care are expected to restrain them from cutting their veins open until they’re back in a more reasonable state of mind.

      • jumpinjacksplash says:

        There may also be a practical point that if someone’s desire to kill themselves comes to the attention of psychiatrists (or other medical professionals, or even friends), then it’s probably not a clear-headed choice. I suspect most people know that if they just unambiguously want to kill themselves then telling people is likely to make that more difficult for them. I’m not saying it’ll just be a “cry for help” or some such, but it implies a level of uncertainty as to whether to go through with it.

        • robryk says:

          I find it very expected to want to consult people you trust on all important decisions. After all, even if your thinking processes work correctly, you can be plainly mistaken in your reasoning. I would even go as far as to claim that if someone is completely certain about an important decision they haven’t talked over with anyone, they’re overconfident. I do not see why that shouldn’t also apply to a decision to cease to exist.

    • meltedcheesefondue says:

      Most people who attempted suicide – but failed – do come to agree that the attempt was a mistake. There’s a repeated predictable irrationality there, one that often ends up with people dead over a momentary dark night of the soul.

      Conversely, if people are able-bodied and rationally decide upon suicide, they can normally find a way.

      So from a utilitarian (not libertarian) perspective, confining people who confess to suicidal thoughts – for short periods – seems justified (though, of course, like any broad measure, it leaves some people royally screwed – for example, those who are rationally suicidal but no able-bodied).

      • John Schilling says:

        Most people who attempted suicide – but failed – do come to agree that the attempt was a mistake.

        Most people who “attempted suicide” but failed weren’t trying to kill themselves, they were conducting a high-risk maneuver to get attention. Their post hoc explanations are probably not a reliable indicator of the mental state of people who actually try to kill themselves.

        Ideally, we want to understand both for this purpose. Have there been any good studies that looked specifically at the subset of people who attempted suicide by high-lethality methods and survived by random accident? I remember looking into this about twenty or thirty years ago and finding some relevant information, but I can’t find it in my files now and I no longer have easy access to a medical library?

        • Matt M says:

          Most people who successfully commit suicide do not report regretting it.

        • Matt M says:

          Not just snark.

          It’s relevant to note that discussing the satisfaction rates among people who choose not to commit suicide is almost irrelevant in the face of having no way to measure the satisfaction of those who choose to go through with it.

          • John suggested a way—use people who chose a method that should have worked but for some low probability reason didn’t. They chose to go through with it, failed, and so are around to be asked.

          • russellsteapot42 says:

            I feel like the most common method that would qualify, suicide by handgun, is also very much on the side of ‘it was an incredibly easy thing to do with an object that was close at hand and which has a lot of suicidal imagery surrounding it in the media’ so given that I’d expect that method to be confounded with a ton of ‘impulsive suicidals’.

            What methods do you think are most likely to be used only by people who are really serious about it?

          • yodelyak says:

            Right. I don’t have any stats to hand, but my understanding is that the majority of people who survive very long falls–e.g. the odd man out who survives going off a suspension bridge or a fourth floor balcony–those people usually regret the decision to jump, and are maybe somewhat more likely to try again than the population, but not as likely as you’d predict if they’d reached a steady-state rational desire to die as soon as practicable.

          • IvanFyodorovich says:

            Re: what Yodalak wrote, the best I’ve found is this review article which notes that relatively few jump survivors ultimately commit suicide, though there’s the confounding factor that some are paraplegic and less physically able to kill themselves. Still, it strongly supports the idea that a lot of people who seriously attempt suicide change their minds.

            If you prefer New Yorker articles to paywalled Scandanavian psych journals, read this about Golden Gate Bridge jumpers. Great quote: “I instantly realized that everything in my life that I’d thought was unfixable was totally fixable—except for having just jumped.”

        • Randy M says:

          Have there been any good studies that looked specifically at the subset of people who attempted suicide by high-lethality methods and survived by random accident?

          I recall seeing this brought up in previous posts on suicide, can’t promise it though.

          • yodelyak says:

            Found it as the second hit on an obvious google query. Here’s a Business Insider article (link) that links to a NEJM study (link).

        • moscanarius says:

          Have there been any good studies that looked specifically at the subset of people who attempted suicide by high-lethality methods and survived by random accident?

          Maybe we could also tease this problem by looking at the people that eventually succeeded in killing themselves after botching once or twice. Are these people who persisted and eventually succeeded in killing themselves more likely to be survivors of the most lethal suicide methods than the rest of the folks that attempted suicide?

        • Ozy Frantz says:

          Some people legitimately want to die but are really incompetent. This is my read of the “banning high-lethality suicide methods reduces suicides” data: large numbers of suicidal people want to die enough to shoot themselves in the head, but are not capable of executing a multi-step plan like buying a gun in a country where it is fairly well-regulated. (Depressed people are really astonishingly bad at things.)

          • John Schilling says:

            Some people legitimately want to die but are really incompetent.

            Yes, and that would confuse the data no matter how we look at it. But there are cases where competence and availability aren’t plausibly issues, e.g. shooting one’s self with an already-owned gun or jumping from the window of one’s high-rise office or apartment, that we could study for the mindset of determined suicides. Most of these people, as Matt M notes, are dead, but not all of them.

            On the other hand, some fraction of the people who slit their wrists across not lengthwise, or swallow a handful of pills that aren’t no how going to kill them, or swallow a handful of pills that will take many hours to kill them and then call their friends/family to say “you’ll be sorry now!”, are genuinely that incompetent in ways that will be difficult to filter out.

          • Nancy Lebovitz says:

            Non-obligatory Inkling reference:

            In Charles Williams’ Descent into Hell, there’s a mention that if a character had brought as much care to his life as he’d brought to his suicide, his life would have been a good bit better. As I recall, this wasn’t presented as funny.

    • Orion says:

      I think that once you’ve waived your libertarian objections to confining people because they’re a “danger to others,” then you’ve given so much ground that “danger to self” isn’t a defensible line to draw. The strongest libertarian argument would be to argue that we ought to lock people up for things they’ve actually done, not for things we think they might do. Many people assume that criminal law is based strictly on what you’ve actually done, and are wary of psychiatry because it isn’t.

      (I personally believe that the criminal code does not recognize a strict distinction between what people have done and what they might do)

      Any living person might do things in the future that infringe on other people’s rights and/or bring negative utility upon them. If you agree that it’s okay to lock someone up because they might do something wrong (or bad) to someone else, then the only objection from personal rights to locking a particular person up would be that their predicted misdeeds are not likely enough or not serious enough to justify it. It’s not obvious to me where to draw that line. If we can lock someone up because he’s likely to commit murder or battery, what about someone who’s likely to commit third-degree assault? stalking & harassment? Arson? Breaking & Entering? I feel confident that by the time you get to DUI or misdemeanor vandalism you’ve gone too far, but I don’t think drawing the line at “murder, attempted murder, or aggravated assault” is right either.

      I think that anyone who is likely to attempt suicide is almost certainly someone likely to endanger others, disturb the peace, or commit a variety of other crimes. Walking into traffic endangers everyone on the road. Jumping in front of a train inconveniences a great many people and could seriously traumatize the driver or witnessing bystanders. Committing suicide with a weapon leaves a deadly weapon lying around unsecured, and a suicidal person who wants to get a weapon might be tempted to commit theft or assault to do so.

      • meltedcheesefondue says:

        There are no libertarian objections to confining people because they are a danger to others. And your argument is that there is no clear demarcation between “danger to self” and “danger to others”. That would only work on a libertarian if the “dangers to others” is sufficiently stark to justify confining the suicidal, which would be a matter of looking at statistics and estimating the knock-on dangers.

        • Orion says:

          There are certainly libertarian arguments against confining people merely for being “a danger to others.”

          Some (many?) libertarians believe that the use of force is only acceptable to thwart an attempt to violate someone’s rights or to punish a violation of those rights. I don’t think most libertarians I would say it’s okay to make “preemptive strikes” against people you merely suspect might violate someone’s rights in the future.

          A typical argument for gun controls takes the form “people who own guns are a lot more likely to shoot people than people who don’t own guns. Gun owners are dangerous to others, and it’s a good idea for the state to take action to end that threat. A libertarian might argue that although shooting people is illegal, owning a handgun should not be, because the state’s power should be used only against people who have actually committed crimes and not against people who the state says are the kind of people who seem likely to commit a crime at some point.

          • meltedcheesefondue says:

            I get that libertarians have strong views on what can get punished, but do they also have principled views on how pre-emptive you can be? I know that they aren’t utilitarian, so you can’t justify it on overall efficiency grounds, but as behaviour escalates – X has an angry, retaliatory streak; X has harmed you in the past; X has threatened you with harm; X visibly conspires with other people to harm you; the conspiracy arm themselves; they start levering a rock to roll over you; the rock is moving, but they could still possibly deflect it, though they are instead cheering it on, etc…

            Would libertarians really insist that one must wait till after the actual harm before intervening?

            I also wonder about negligence. If someone has a barrel of toxic waste slowly rotting next to your property, would they only allow intervention after it spills? How close to 100% does the probability of future harm have to be?

          • Radu Floricica says:

            I’m seeing in the (US?) media and forums a lot more of a caricature of libertarians than actual libertarians. Stopping somebody from hurting somebody else is plain common sense – to be perfectly honest, I’m a lot more inclined to treat this as a false-flag attack than anything else.

            But even among libertarians, there are more discussions on how private police would be a good thing, or how all taxes are theft, than orders-of-magnitude more low hanging fruits like agricultural subventions are bad. Or regulatory capture. Or any number of non-controversial, evidence-supported things which would actually improve everybody’s lives a lot.

            But on the other hand, the little I read about the Libertarian Party in the US makes me think of, no offence, loonies.

          • Matt M says:

            Would libertarians really insist that one must wait till after the actual harm before intervening?

            As a general matter of principle? Yes.

            In practicality, not necessarily.

            In other words, I believe the “law” (what law is under a libertarian system is very different) should be that you CANNOT initiate force pre-emptively, period. But if I were on a jury, I would refuse to convict/punish someone who, say, shot someone else who had a gun pointed at someone and seemed as if they intended to fire.

          • My guess is that most libertarians would agree that if someone points a gun at you with obvious intent to shoot you, you are entitled to grab the gun before he pulls the trigger.

    • Douglas Knight says:

      A fanatic is one who can’t change his mind and won’t change the subject.

      This post is about navigating the system that actually exists. Scott wrote a separate post defending the system. Take your comments there. (And is this really in your top 1000 libertarian complaints about the US government?)

    • holomanga says:

      There’s this weird edge case where something weird happens to your decision-making organ that makes it report “death” as a good strategy for a stretch of a few months at a time (and sometimes much more, up to your entire life, which is sad). Before and after, you’ll be really sure that you don’t want to die.

      If you actually want to die, there’s a really easy hack that I definitely don’t recommend: not tell people.

    • jonm says:

      OK here’s my set of slippery slope cases and I’d be interested where you would draw the line about what suicide you would be willing to prevent. Note that in all these cases the person is only a danger to themselves.

      1) Your worst enemy slips a chemical into your food that makes you temporarily suicidal
      2) You accidentally ingest the same chemical that makes you temporarily suicidal
      3) Your clothes are accidentally laced with the same chemical that makes you temporarily suicidal
      4) Your kidneys occasionally produces that same chemical automatically for short periods which makes you suicidal
      5) Your brain occasionally produces that same chemical automatically for short periods which makes you suicidal
      6) The complex chemical processes etc of your brain occasionally coincide so that you temporarily are suicidal

      I would argue that 6 is a reasonable model of many cases of suicidality. I would also argue that cases 5 and 6 are clearly morally identical. Who cares whether the process is one chemical or a bunch of them? I’m not clear that case 4 is so different either, does it really matter which part of your body the chemical is produced in? And in that case, is it so important that it comes from within your body rather than from outside. And if we’re allowing it to come from outside what difference does it make about whether someone did it you or it happened accidentally.

      • engleberg says:

        Milton ‘On His Blindness’ could wish that he had Samson’s leave against self-destruction. Are you a Jewish superhero shaved into weakness by Delilah, blinded by Philistines, and chained to the support structures of their temple while your hairy strength regrows? If so, God is cool with you killing yourself to kill them. Samson is a solar myth, so in some sense all our luggage is Samsonite. On the other hand. Get a grip chemistry boy.

      • actinide meta says:

        “You” ought to be able to decide (in advance) which, if any, of these situations you would like to be restrained in and who you trust to make the decision. It’s the idea that the same balance of these factors has to be imposed on everyone that’s fundamentally “unlibertarian”. The mental health system could respect powers of attorney, advance directives, etc, but I don’t think it does.

        • jonm says:

          I’m going to take a wild guess and say that you don’t have an advance directive that covers most of the above scenarios, so how does that help? If you do, then I think most people would be happy to follow it assuming we can even tell which scenario applies.

          But for public policy terms, we’re going to have to make a reasonable guess about what people would have wanted in advance or given the space to reflect etc. I don’t see why the default should be assuming they wanted to die if their brain briefly enters a suicidal state.

  10. Calvin says:

    As a lawyer:

    Some people wait until they get out, then comparison-shop from the outside world and hire a lawyer to sue the people who mistreated them in the past. If you’re going to do this, document everything. Your doctors are documenting everything, and if one side comes in with perfect documentation and the other side just has vague memories, the first side will win. By “document everything”, I mean have a piece of paper where you write down things like “2:41 PM on October 10: Nurse Roberts threw a pencil at me. Informed such-and-such a person and they refused to help. Informed such-and-such another person and they also refused to help.” Write down exactly where and when everything took place – the psychiatric hospital may have video surveillance, and if everybody knows which videos to get, it will make life much easier.

    YES. ALL OF MY YES.

  11. MissFortune says:

    So dude, real talk here.

    I’ve been committed twice, it was completely horrible as in still wake up in cold sweats traumatised horrible 10 years later. Since then I’ve kept a wide berth from doctors of all kinds despite nothing actually being better.

    From the sound of it my suspicions about not being able to talk to a doctor about the extent of my problems without going back to a setting which, does not work for me are correct. In a situation like mine, as I imagine I’m not unique, where suicide is a likely cause of death but plans to make that happen aren’t immediate do you have any suggestions for pursuing treatment in some way that would not land me in hospital?

    • __phoenix13 says:

      Perhaps consider OTC options? I know it’s often hit-or-miss with anything, but there are at least some options for trying to get help without getting involved with the formal mental health system.

      http://www.thedoctorwillseeyounow.com/content/depression/art4215.html sarcosine, 2-4g

      https://www.webmd.com/diet/supplement-guide-sam-e#1 SAM-e, 400-800mg

      https://www.nootropedia.com/tianeptine/ tianeptine sulfate, 12.5-50mg/day – note potential risks

      It’s also possible to just outright buy prescription antidepressants online for shipment into the U.S., but it’s tricky to find sources, often expensive, and may not be a good idea if you don’t already have an accurate sense of how different substances affect you. I mention it only because many people seem unaware that it is in fact legal.

      Other options exist as well. Merely listing the ones that have worked best and most consistently for me. Your story reminded me of one of my friends.

    • antpocalypse says:

      This may not be the case everywhere, but a lot of the people I’ve seen have positive mental health treatment experiences have a non-MD outpatient therapist/counselor as their primary provider. It’s somewhat harder to get involuntarily committed in that setting unless you say, “I’m going to walk out of your office right now and ” in which case they can call the police just as well as anyone else can. Often you can get more face time with them than with a psychiatrist and develop a relationship where they have a good idea when you’re in serious imminent danger and when you’re just voicing difficult/frightening thoughts and feelings. If medication is necessary, they can refer you to a psychiatric nurse practitioner (or psychiatrist) who can prescribe without taking your treatment over entirely.

      As Scott mentions in the post, it’s entirely possible to develop this kind of high-trust relationship with a psychiatrist and have an equally fruitful treatment experience. Unfortunately, it’s also possible to get someone that you can’t communicate well with (or who just sucks) and has an itchy finger on the commitment trigger, and it really only takes a couple of those to make one not want to roll the dice again.

  12. Murphy says:

    One note for people in the UK:

    “How can I decide which psychiatric hospital to go to?”

    You can look up the cqc rankings of various NHS mental health trusts:

    http://www.cqc.org.uk/search/services/all?f%5B0%5D=latest_inspections%3Amonth&f%5B1%5D=im_field_more_services%3A3663&f%5B2%5D=im_field_inspection_rating%3A3926&f%5B3%5D=im_field_popular_services%3A3958

    Now, normally, the hospital you’d be admitted to by default would be based on the borough in which you’re resident unless you need specialist care they can’t provide.

    However. If you are of “No fixed abode” you’ll typically be admitted at whatever trust you present at. If your local hospital is particularly shoddy for some reason and you’re set on seeking inpatient mental health care then it may be worth presenting as having been “kicked out of home”/”broken up with your SO”/etc and thus of “no fixed abode” on the doorstep of somewhere like SLAM mental health trust.

    And of course the cost part of the equation can be largely removed as a stressor in the UK.

    Also, if you don’t want to be restrained and end up with an injection of sedatives 1:avoid attacking people while on the ward and 2: if there are medications you’ve been prescribed that help prevent you from ending up in a state where you’re prone to attacking people take those 3:if there are things you need to keep being alive like life-saving medication then take those meds because the staff, not entirely unreasonably, dislike restraining people (there’s lots of paperwork) but absolutely will if the alternative is having to deal with preventable deaths or injuries on the ward.

    • jumpinjacksplash says:

      Stating you have no fixed abode is risky; you need to then be very sure you’ll have someone outside who’ll say you can stay with them long-term (whether or not that’s true), or it may cause you problems being released. Simply stating, “Oh, I lied when I was admitted” is unlikely to help.

      • Murphy says:

        Unless you’re in a state such that you can’t care for yourself they really don’t want to keep you longer than they have to. Though there are typically staff who’s job it is to liaise with the council to sort out some kind of emergency housing for patients being discharged with nowhere to go. Keep in mind it probably costs the local council more per night you’re in the hospital than per month you’re in a normal rental room.

        And hey, depending on your mental health problem when you were admitted you may have believed all kinds of things, perhaps it left you convinced your family really didn’t want you at home.

    • b_jonas says:

      Also at least here (in Hungary), having no home doesn’t give you a choice for which hospital you get committed into. It usually gets you into a very unpleasant hospital ward full of other poor people who don’t have a home. There’s a roster of which ward gets this depending on the day of week.

  13. Neb says:

    If you decide to open up to the nurse-assistant giving you a three question psychiatric screen in the pneumonia ward, you may end up on a psychiatric unit regardless of how careful you are, because hospitals don’t take chances.

    Hmm. I went to the ER last year with chest pain and got asked some routine mental health questions along the way. I’m sketchy on the details of exactly what I said (it was a rough night), but I know I said something about a history of depression and medication. Was that a mistake? In the (hopefully hypothetical) future, should I not say anything at all?

    • Murphy says:

      If you’re currently on any meds it’s important they know. Don’t want any surprise nasty interactions if they have to send you to surgery.

      My guess:

      if you’re already on meds and you’re there about something else then that’s something that’s already being treated and implies that another doctor thinks you’re ok enough to just be on some meds.

    • Ozy Frantz says:

      You should definitely tell your doctor about any meds you’re on, but IME if you’re like “I’m on Zoloft and I’m not depressed” you will not face any negative consequences, they’ll just assume the Zoloft’s working.

    • Neb says:

      Yeah, letting them know about medication is what my thinking was. In all other situations I’ve always stuck to a version of what Scott is recommending here when dealing with mental health professionals. At most they get, “Once, in middle school… but I haven’t realistically considered the possibility since…”

    • Garrett says:

      I volunteer in EMS. This isn’t quite the same as the ER, but is similar.

      The question I ask most often to my patients is “do you have any chest pain or difficulty breathing?” Why? So that I can legitimately document on the patient chart that “Pt. denied any chest pain or difficulty breathing.” It’s a CYA thing. The fraction of people I deal with who are on some set of anti-depressant is astounding. Just about everybody in a nursing home. Everybody with depression, anxiety, chronic pain (sometimes off-label), fibromyalgia/chronic fatigue syndrome/I don’t know what else to try/these look like good placebos gets them. Whatever.

      Most ER folks are asking these questions so that they can check the box that allows them to testify “I did everything reasonable”. For example, if you say “yes – I take antidepressants every morning, as prescribed by my psychiatrist, and they help a lot” you’re pretty much done. The big things that the ER has to worry about are “threats-to-self-or-others”. You know what signals that you’re on the right track? Showing up to the ER with a real complaint (like chest pain) and being able to answer questions reasonably! For bonus points, actually knowing the medications you are on and why you are on them! “I used to be suicidally-depressed and then my psychiatrist prescribed Happify (50 mg, once a day) and now I go parasailing on the weekends!” Or “I take my medication as-prescribed and it doesn’t seem to be doing much. I have an appointment with my psychiatrist in 2 weeks for follow-up”.

      The goal of the EMS/ER staff is to get just enough information that they can justify not caring about everything that isn’t your chief complaint that’s likely a life-threat. It’s all about being able to testify on the stand that there was nothing reasonable given the information presented that could have been done.

  14. Cecil Harvey says:

    I take exception to saying that there’s little real difference at voluntary vs. involuntary commitment. Perhaps not during, but afterwards, there is. If you are a firearms enthusiast, it’s a life-changing difference. You permanently lose your right to own or operate a firearm. In theory, you can get this reversed, but at great time and expense.

    There have been a handful of prominent firearms trainers in recent years that have committed suicide. They never spoke to a mental health professional because of fear of permanently losing their rights, and thus their livelihood.

    Please note, I’m not debating gun control here, I’m just stating that there are real and genuine consequences to being involuntarily committed. I’m sure there are others (probably differing quite a bit from state to state).

    • Orion says:

      I believe what Scott was saying is that while you’re in hospital it makes little difference whether you’re voluntary or in voluntary. He explicitly mentioned involuntary commitment as something to avoid when possible because it can turn up on background checks.

      The question he was answering was about how to make sure people on the inside know whether you’re voluntary or involuntary, and I understood his answer to mean that you needn’t bother because people on the inside won’t care.

      • Cecil Harvey says:

        I get that this was his angle, but I think my point is important for a lot of people to consider. Background checks are important for a lot of people that wouldn’t otherwise think of them. Firearms, lots of government jobs, any jobs that require working with children, taxi drivers in some states, etc. It’s a really important distinction.

        As a firearms enthusiast, and the sole bread-winner of my family, I don’t know what I’d do if I thought I needed psychiatric treatment. I in general don’t trust doctors (there are exceptions — some have earned my trust) as having my best interests at heart. I certainly find this article interesting and enlightening.

        • Matt M says:

          And the political momentum is to make this situation worse, not better. People want further crack-downs on the rights of anyone who has ever been declared “mentally ill” by anyone else.

          • Cecil Harvey says:

            I couldn’t agree more.

            I think there’s a good balance to strike between the danger someone poses to society and individual rights. But striking a good balance is hard, messy work, so the knee-jerk reaction to make the life hell on someone who just needs a little help is staggering. And, frankly, I hear exactly the same crap coming from both the right and the left.

            Again, I feel incredibly fortunate that I don’t need such treatment myself, but I’ve seen the system crush people who do.

    • christmansm says:

      Federally and in most states, “involuntary commitment” for the purposes of gun ownership is judicial commitment AFTER the initial hold, not the initial hold itself. Only a small fraction of people who have been initially committed ever make their way into the background check system, so it’s largely moot anyway.

      Some states do have additional restrictions that apply to firearms ownership after 72-hour holds, but these are likewise not consistently enforceable, and in at least one decision unconstitutional given the lack of due process.

      • The Nybbler says:

        A 5150 in California is a bar to firearms possession. I believe it’s the similar PA 302 that was struck down as a Federal bar. It doesn’t matter whether it actually makes it to the system since they ask the question on the form; if you’re up to no good, you might get away with lying, but if you’re not up to no good you’re risking prosecution for perjury if you do.

        Besides, there’s no bar for disqualifying conditions being added retroactively. The ex post facto law provision is dead as long as the State is willing to pretend the restriction isn’t punitive.

  15. Freddie deBoer says:

    Too damn real.

  16. fortaleza84 says:

    Another issue to consider is that when you apply for life insurance, the carrier will typically require you to sign a waiver authorizing them to review your medical records. So a stray remark to a doctor could cause you some problems even if the doctor didn’t take it seriously.

    Or if you sue your employer for failing to accommodate a disability you can be required to authorize release of your medical records.

    So you have to be a bit careful when talking to any kind of healthcare professional even beyond concerns of involuntary commitment.

  17. ADifferentAnonymous says:

    I have no clue about it’s psychiatric validity, but you can buy cannabidiol concentrates legally in a lot more places than you can get recreational marijuana: https://www.leafly.com/news/politics/cbd-oil-legal-depends-ask

  18. pacificverse says:

    Where I come from, I think you need familial permission to involuntarily commit someone. And a doctor’s recommendation and a judge’s approval, of course.

  19. The Nybbler says:

    I’m not going to rant like the first poster, but I already had a prior against the mental health system, the first point definitely reinforced that prior, and the rest of it have left it on the close order of 1. You’d have to be crazy to get involved with it at all, it seems. (So maybe that counts as working?)

    • Orion says:

      I think you overlooked a very important prior — this article is written as advice for people who have delusions, suicidal thoughts, or other symptoms of the type that get people committed, such as manias,

      If you’re not psychotic or suicidal, I don’t think anything in this post should deter you from seeking treatment for anxiety disorders like OCD, PTSD, social anxiety, and the like.

    • IvanFyodorovich says:

      Pure anecdote: when I was a younger and sadder man, I’m sure I told psychiatric professionals that I had suicidal thoughts, and I had friends who engaged in parasuicidal behaviors (e.g. cutting), and none of us ended up institutionalized, even briefly. The scenario Scott is protecting you against of “tell shrink you are vaguely suicidal, end up in mental hospital against your will” probably does happen but I don’t think it’s very common. To the extent it does happen, I imagine it is more common if you are encountering the psychiatric system because of something bad or troubling you did, as opposed to is you are hiring a shrink of your own volition. A psychologist in the suburbs is not going to keep clients if she keeps involuntarily committing them.

      • Protagoras says:

        Scott is pretty clear that the scenario is especially a risk in hospitals; the psychologist in the suburbs you mention is one of the outpatient therapists he says are much less likely to involuntarily commit people.

  20. Matt M says:

    Side question for Scott – what happens to homeless (or otherwise obviously resource-lacking) people who might otherwise be in need of involuntary confinement?

    As in, what does the system look like for people who quite clearly and obviously cannot, and never will, be able to pay? Do they still get admitted for public safety reasons? Or does everyone involved do their damndest to find a good justification as to why this guy is totally safe and not at all a threat to anyone?

    • Orion says:

      They go to prison.

      (Kind of a joke but not really)

    • alwhite says:

      If a homeless person enters an ER with an emergency, they are treated and the cost gets deferred to the state. After some period of time, when they are treated, they are released and go back to living on the streets until the next emergency.

      If a person is an obvious threat and they resist treatment, like taking meds, they can be transferred to a different hospital for longer term care. This is not a fun place to be and you should avoid it if you can.

      It’s important to note that the truly mentally ill aren’t really a big threat to the rest of society. They are often homeless because they can’t find/hold jobs, etc, but they aren’t really dangerous. It’s very easy then to release those people to the public. Another option is prison. A lot of these people get caught on drug charges and possibly burglary. They then go through a cycle of prison, the streets, prison, until they just get life in prison.

      A “homicidal maniac” (doesn’t really exist) would probably have issues with the law and be in prison before they got to a hospital.

      • The Nybbler says:

        A “homicidal maniac” (doesn’t really exist)

        Tell it to the people who have been pushed onto train tracks or slashed in the face by mentally ill homeless people.

        • alwhite says:

          These are not examples of predictable homicidal behavior. Nor are they examples of “homicidal maniacs” being overly present in the homeless or mentally ill populations. They are examples of homeless people doing violent acts. That’s true. By that same logic all human beings would be homicidal maniacs because there are examples of humans doing violent acts.

          Mentally ill people are way more likely to be the victims of violence than the perpetrators. Just because you can find a few examples doesn’t mean you’ve identified a classification to apply to people.

          • The Nybbler says:

            Mentally ill people are way more likely to be the victims of violence than the perpetrators.

            Which factoid, even if true, does not mean they aren’t more likely to be perpetrators than the general population, nor does it rule out a subgroup of “homicidal maniacs“.

          • alwhite says:

            The fallacy here is that you are not comparing to how many homicides happened in that same time period. All your study proves is that homeless and/or mentally ill prefer trains as their mode of assault, not that they are inherently more violent than the general population.

          • Matt M says:

            All your study proves is that homeless and/or mentally ill prefer trains as their mode of assault, not that they are inherently more violent than the general population.

            If the homeless/mentally ill disproportionately:

            1. Carry out their violence in crowded, public places

            2. Select their victims essentially at random

            That makes them significantly more dangerous than other groups of criminals. Gang violence is responsible for a whole lot of murders in the US, but most people don’t especially fear it – because for the most part, it’s relatively easy for most people to avoid.

          • @Alwhite:

            Your response would be a reasonable one if you had not previously written:

            A “homicidal maniac” (doesn’t really exist)

            For that to be false, homicidal maniacs don’t have to be “overly present in the homeless or mentally ill populations.” They just have to exist.

            And the way you put it makes no sense. A homicidal maniac is by definition mentally ill. Hence as long as there is at least one homicidal maniac, homicidal maniacs must be more common in the mentally ill population, since it includes all of them.

    • christmansm says:

      There are usually some inpatient beds at state hospitals, generally not enough. Nonprofit hospitals tend to provide some charity care, again not enough. If people can wait long enough, a bed will generally open up.

  21. Garrett says:

    A bit of perspective from other providers. I volunteer in EMS. I occasionally transport psych patients. My experience is even more limited than Scott’s, and might be slightly wrong.

    If you want to be admitted and are at home and can’t wait to get transport to the hospital, you can call 911. Provide some idea why. When EMS shows up, they’ll ask for more details. You pretty much have a right to be transported to the hospital. Tell them that you want to go to a psych ER.

    Involuntary commitment. In my State, EMS providers do not have the legal authority to unilaterally transport someone for psychiatric reasons against their will. In some States they do. However, there are 3 common ways that involuntary transport/evaluation can occur: police protective custody, mental health warrant, and doctor’s order.

    Police “protective” custody happens generally when someone is acting “as-seen-on-TV crazy”. It is also likely if EMS requests that this happen, but it is a separate and independent legal judgement of threat-to-self-or-others. In these cases, the person is arrested and then handed over to EMS for transport/evaluation. The police don’t like to do this if they can find a way to make it somebody else’s paperwork, however, which leads us to:

    Mental health warrants. This usually involves a field social worker on-scene swearing out a warrant over the phone to a judge who authorizes it. If you are able to speak coherently, this is the likely involuntary transport method. However, it’s more complicated than this. Incidents like this usually start off either with a relative noticing that something is “wrong” with the person, or some kind of argument where someone utters the “I’m going to kill myself” line. Police are frequently involved, but mostly as facilitators/bodyguards until we all know what’s up. Then the social worker (as Scott noted, over-worked and under-staffed) will arrive and try to sort the matter out. If they decide you need to be evaluated, *you are going*. Full stop. The only question remains whether that’s “voluntarily” or “involuntarily”. (Legally, a judge approved the warrant, but in-practice no judge is going to refuse a professional social worker on-scene surrounded by police and EMS) As Scott noted above, it’s not really a choice. Still – agree to go voluntarily! Being a voluntary patient who is calm for the ambulance ride is more likely to get you processed more quickly, better treatment, and thought of as someone who can at least appreciate the situation they are in. If you don’t go voluntarily, you’ll still end up in the same place, likely transported by police or ambulance, only with a report given to the doctor of “not cooperative”.

    Doctor’s order. In rare cases, usually by EMS requesting an order from our medical command physician, a person can be ordered transported to the hospital ER for a psychiatric evaluation. I’ve only encountered this once.

    In all cases, you’re going to the hospital. Be as honest and use the rest of Scott’s information as appropriate.

  22. fustruly says:

    Can I add, if you’ve been given treatment that isn’t working, and nobody seems to care, but you definitely want to have functioning treatment before you get out and you’re still lucid:

    When they do rounds and ask how you’re doing, just say “I’m fine.” When they follow up with, “Are you still experiencing [reason for being here]?”, just say “Yes.” If it’s drugs, then when the nurses give you your drugs, say “I don’t want to take it,” in a level-headed, non-aggressive tone. They will probably sympathetically say, “Please take it anyway.” Then take it. (Also go to group.) Everyone will be on your side that you should have a different treatment and it will probably happen fast.

    If you’re throwing a fit about your treatment not working, they often get defensive, or take this as a sign that you clearly need a higher dose or more frequent treatments or something, and it makes you less credible. If you throw a really big fit, they might have to physically restrain you and give you your treatment forcibly, which is a bad day for everyone. If you’re being obnoxious and playing up your symptoms and side-effects in a silly way, everyone will be annoyed with you and might suspect that you’re making a joke out of having a bed that lots of other people are desperate for and they won’t listen to you as much. If you lie about whether you’re still having the problems you arrived with, you could be discharged without enough of a plan for treatment, and that’s when things go from bad to worse.

    I bring this up because I’ve watched fellow patients (directly) and friends (remotely) go through all of the above missteps and it is very sad.

  23. Mosoph says:

    Can someone explain to me, or link me to an explanation of, how long-acting injectable pharmaceuticals works? I was wondering about this the other day in the context of Depo-Provera (the contraceptive injection) and I didn’t know that other meds are given in a similar form.

    I don’t have enough of a medical or biochemical vocabulary to look this up on my own. I don’t need an ELI5; I can look up medical terminology and biochemical processes just fine. I just need the key terms to search for.

    • christmansm says:

      Most traditional long-acting injectables have relied on a large injection into a muscle, from which the drug is slowly released over weeks. Depo-Provera is the same exact drug as its oral contraceptive equivalent, just way more and injected into a muscle. A lot of long-acting injectible antipsychotics couple the active molecule to some ester like haloperidol decanoate, which ensures slow release. Some are subsequently metabolized into the active drug.

      The long-acting risperidone (and I think naltrexone) formulations are different, and rather interesting. They encapsulate the medicine in tiny spheres of biodegradable polymers like polyglactin, the same stuff used in absorbable sutures. The spheres slowly break down, releasing the active ingredient.

  24. Nott Alexander says:

    Anything written with too much honesty risks degenerating into “here’s how to cheat the system so nobody will know you’re about to commit suicide”. But anything written with too little honesty risks degenerating into some variation of “trust the wise benevolent doctors to do what is best for you”. This is an impossible edge to balance on, and I am sure I fail at one point or another.

    I definitely think you erred on the side of “too much honesty” on this one, which isn’t necessarily a bad thing, but makes me a little scared for you in particular. If this were my dental license on the line, I’d be super paranoid about someone finding this and reporting it to the Board, especially if I was popular enough that people could start resenting me for arbitrary and weird reasons without having ever met them.

    Then again, my priors for “the board will take away your license for LITERALLY ANYTHING, ALWAYS BE ON ALERT” are exceptionally high. Mostly because I like to overcorrect myself when it comes to estimating the damage that can be done by the negligent, huge, overcomplicated, and capricious god that is The Bureaucratic System.

  25. Orion says:

    I do not understand this comment software. I’m reading the comments, and some of them come with a “reply” button, and son don’t. I can’t figure out why, and I’d like to reply to a comment I’m apparently unable to.

    • Matt M says:

      It’s due to the finite amount of nesting that the page supports. If you want to reply to a lower-level comment that has no “reply” link, best practice is to scroll up to the higher level comment (the first one you find that has a “reply” link) and reply to that one, and your reply will show up at the bottom, near the comment you wanted to reply to. You can click the little up arrow to automatically go to the higher level comment as well, which is the one you should reply to.

  26. MichaelF says:

    Scott, I think your post is ignoring the elephant in the room. People with OCD are often afraid that if they tell psychiatrists the content of their thoughts, they’ll be locked up. How much of this fear is justified?
    Speaking of commitment, I was wondering if anyone saw the Chicago Med episode “Down By Law”. It was one of the first depictions of OCD on the Big 4 networks that didn’t feature germs or hand washing or whatever. And I thought it was horrible. The patient is scared he will harm his wife and wants to be committed. And Dr. Charles wants to commit him! Trying to be committed is a compulsive act- you don’t reinforce the patient’s compulsions. Then Dr. Charles says people with OCD that are afraid of hurting people might really be dangerous- which is true, in the same sense that someone that has a phobia of being killed by a meteor might really be killed by a meteor.
    The episode portrayed Exposure and Response Prevention therapy incorrectly and weirdly portrayed it as working but suggested that doctors who tried it were reckless.

  27. __phoenix13 says:

    Just thought I should leave this here:

    Sarcosine is a non-SSRI that vastly outperformed citalopram in a head-to-head human clinical study. It is available without a prescription and is quite cheap. It had no significant side effects in the study, and a much lower rate of discontinuation due to tolerability reasons than citalopram:
    https://www.medscape.com/viewarticle/815027
    http://www.thedoctorwillseeyounow.com/content/depression/art4215.html
    etc.

    If you are severely depressed but afraid of seeing a psychiatrist, it may be a potential option. 2-4 grams per day.

    Of course, tianeptine sulfate is also available online without a prescription, but it’s important to avoid going over the recommended dosage. Also some people have reported side effects, which may be more common than sarcosine.

    SAM-e in high doses (400-800+mg) also seems to help a bit, for at least 4-8 hours anyway.

    It’s important to admit that some people are too concerned about the risks to their personal autonomy, dignity, careers, etc. to risk speaking with a psychiatrist about these problems in the first place, or may merely not have enough money or time to manage it. It is reasonable for them to try non-prescription options first before escalating to riskier and more costly potential treatments.

    Frankly, given the often severe and sometimes even permanent side effects of many SSRI antidepressants, it is my view that medical staff should consider lower-risk options like the above first. But of course, the incentives of the current medical industry do not favor such approaches.

  28. Bugmaster says:

    This sounds pretty horrifying; it seems like even if you were sane going in, you’d end up insane coming out of that system.

  29. Merky Watterson says:

    In Finland you’re put to involuntary care if public care nurse feels uncomfortable with you. Been there done that. There is even one case where chainsaw juggler told about his profession to doctors and was taken to hospital because they simply didn’t believe he had a gig coming in North-Korea.
    They didn’t even bother to check if he was telling the truth, which he was.
    And when you’re put in, practical treatment is torture and humiliation at best.

  30. libberosthoughts says:

    About allucinations, there’s the phenomon of Tulpa which pseudo-normalizes it. Do you have a psychiatric take on it?
    Also, as an European, where is the 5000$ bill on point 2 coming from? Is it just for the ER visit or the extra psychiatric consult?

    • walterthedog says:

      It could be either, depending on the hospital. ER charges vary widely.

      My one trip to the ER as an adult (knock on wood) yielded a $2500 bill for roughly 10 minutes of contact. I received an anesthetic injection that to get me through (most of) the night, until I could get to a dentist.

      I suppose that if I were to agree to pay $15000/hour for medical attention, dental pain exacerbated by sinus infection would qualify. [/digression]

      Of that, something like $1800 was a blanket “intake” fee. The other $700 was split more or less evenly between ‘supplies’, the nurse who gave the shot, and the nurse’s supervisor (probably for approving it). I had a high deductible plan at the time, and paid all $2500. I had hoped that the ER (a university hospital) would negotiate, but no. I didn’t meet their standards for financial hardship.