Involuntary Psychiatric Hospitalization Can Be Horrifying
An open letter to Eric Adams, NYC Mayor.
I learned this week that the government of my city, New York, is advocating for reducing restrictions on police officers bringing individuals in for mandatory psychiatric care against their wills. We’ve discussed why emergency care is problematic in this Substack before. This directive from the mayor is for people who are not meeting criteria for imminent risk to self or others. Which is to say, it’s a much looser rule, and we know how well the police deal with loose rules. I’m providing this helpful primer to explain just how abysmal this idea is.
It’s worth noting many of the individuals who end up homeless and in need of help OR targeted for coercion are Veterans of our military. A community is working to end veteran suicide at Veteran Mission Possible.
Now, there are other parts of Mayor Adams’ 11 point plan that are a good idea. In this broader context the following is completely unfair. But, I’m making a point here, specifically about the first point on the plan. Maybe I’ll handle the other points in a subsequent article. However, changing standards regarding involuntary care by mayoral decree is what I’m addressing here. It’s a huge decision. And a huge problem. This point needs to be addressed separately for that reason.
See Them Diplomas? I’m a Credible Expert
I am a psychiatrist. In order to avoid protesting too much, I’m just going to screenshot the most relevant page of an 18 page long curriculum vitae:
Suffice to say, I am an expert at managing psychiatric emergencies.
My Open Letter to Mayor Eric Adams:
Sit down. It’s not actually a request. This is coercion. When the force of the law says sit down, you have to do so.
It’s not a suggestion, Mr. Mayor. Yes, I understand you were trying to:
address “a crisis we see all around us” toward the end of a year that has seen a string of high-profile crimes involving homeless people, Mayor Eric Adams announced a major push on Tuesday to remove people with severe, untreated mental illness from the city’s streets and subways.1
You may be new to the ability to hospitalize people psychiatrically against their will, but I am not. I have been doing it for a long time. I have been a licensed physician in the state of New York since 2012. I am a dual board-certified psychiatrist in both general and child and adolescent psychiatry.
And it’s for your own good, because I say so.
When I say, sit down, you sit down. If you don’t sit down, I’m going to be concerned for your safety and the safety of my staff. In a psychiatric emergency room, I have the right to force you to do many things, by virtue of my medical license together with mental hygiene law.2
I understand your legal counsel has tried to redefine that very clear law for political expediency:
Brendan McGuire, chief counsel to the mayor, said on Tuesday that workers would assess people in public spaces “case by case” to see whether they were able to provide basic needs such as food, shelter and health care for themselves.
Let me tell you what coercive measures are allowed in a psychiatric ER:
I can have you grabbed by men and women and held down while you scream and shout and flail about uselessly. If you struggle too much, in addition to being held down physically, there is more I can do. You would be strapped to a gurney. Being strapped to a gurney against your will might be horrifying—and I mean this in the most literal sense of the word: it induces a sense of horror.
This is such a horrifying experience, that, absent, a medical license and ample documentation, what I’m describing here would be a literal crime. It’s called aggravated assault (and maybe kidnapping) at best.
Now, Mayor Adams, you should understand:
This is for your safety. But since you’re screaming, and it’s disturbing the other patients, one of the things I’m able to do is inject you with medicine. No, you don’t get to say no. It’s an emergency. And because it’s an emergency, I have the right to “treat you” over your objection.
Physicians exercise this power with great caution because, unlike police officers, there are consequences to our actions, and we can be sued for medical malpractice, disciplined, and have our licenses revoked for inappropriate use of these interventions. The police can and do suffocate and shoot people of color with mental health histories. 72% of those killed by police officers have a psychiatric treatment history. Of those violently killed by police, though the majority are white, there are a disproportionately high number of black people killed, and they have the following mental health history profile:
Here is what treatment could look like in a psychiatric emergency setting, Mayor Adams, were you to be brought in under your new mandate:
I can do almost anything I want to you. I can make you unconscious. I can do that with ketamine, I can do that with Haldol. I can do that with a mixture of Ativan, Haldol, and Benadryl. And if you’re agitated when you are coming out of that stupor, I can give you more drugs. I can give them to you through an intramuscular injection. I can give them to you through an intravenous line that I put in. While you’re strapped down, I can invade your body with needles and drugs. I can strip you naked and force you into gowns, and “for safety”, remove you from contact with any friend or family.
I have ordered these things in medical settings. I have been personally trained to perform involuntary restraint along with nursing and direct care staff as an Office of Mental Health (OMH) employee of the State of New York. The things I’m allowed to do to people by virtue of a medical license is the standard of care when it comes to managing agitation. It would be a war crime if I did them to terrorists in a war zone. Even if they were subdued, after actively attempting to shoot me, I would have none of the rights that I have in the ER. In a medical setting, I can do as I see fit to manage agitation, with appropriate documentation—but there are consequences if I don’t.
One of the things that makes this even remotely acceptable now is that when people are brought into the emergency room, in handcuffs, by police, by virtue of the fact that that is the way they came in the door, we have a sense that the police use some judgment in doing so.
If the police bring someone to an emergency room, it’s because they were dangerous in the community. Because that’s the law. We make an assumption, in some cases based in large part on the information conveyed by the officers and Emergency Medical Services (EMS) about why the person is there. Acute danger is different from chronic risk and political posturing.
By reducing the standard of risk by which someone can be brought in the door, you limit information which determines who is a risk or not. Emergency physicians, particularly those dealing with behavioral emergencies, tend to be skeptical. Most people who are brought into the emergency room in handcuffs say some version of “this is a big misunderstanding”.
Our job is largely to obtain collateral information about why the person was brought in and what was so dangerous about their behavior. By changing the standard by which people can be brought in, you hamper our ability to do a good job of caring for those same humans.
Because we won’t know why they’re presenting for care. And if we don’t have EMS there, I strongly doubt we’re going to get a great medical history. Remember medical conditions? It’s one of the reasons Eric Garner died in police custody. He had one, and no appropriate evaluation was done.
Psychiatrists are not psychic. We don’t know what’s wrong just by talking to someone. We’re trying to put together a story about what might be wrong by being health detectives and investigating the story, in order to determine what to do.
Your executive order makes our job much more difficult. Crucially, even if your officers are told to ignore mental hygiene law, we can’t. If someone is brought in for evaluation because your officers found them in a park, we still can’t legally admit them, as physicians, because we would lose our licenses by admitting patients in contravention of mental health law around involuntary commitment.
And one more bit of nitpicking:
Brendan McGuire, chief counsel to the mayor, said the state mental hygiene law had provisions that allowed for people to be involuntarily committed to an institution if they were determined to meet certain criteria after diagnosis by a doctor. “They do not need to consent” to the treatment or diagnosis, he said.
This is almost completely false, although you can admit someone against their will if they meet a minimum legal standard (this is the lowest bar for involuntary admission, called 2PC, short for 2 physician certification), which is as follows:
A person has a mental illness for which care and treatment in a mental hospital is essential to his/her welfare; person's judgment is too impaired for him/her to understand the need for such care and treatment; as a result of his/her mental illness, the person poses a substantial threat of harm to self or others.
What this standard does not allow for is medical treatment over objection. This standard only covers the admission to a psychiatric hospital. This experience is often so coercive that the person in question will either relent and take medicine just to get out. In other cases, the inpatient team has to petition a judge, and win, in order to provide involuntary medication treatment in the hospital. We need to persuade most people. And judges can and do block the ability of psychiatrists to force care onto people who aren’t acutely at risk.3
How Long Could Mayor Adams Stay Locked in a Psych Unit if He Was Admitted Under His Own Order?
When I have completed my immediate task of managing a patient’s agitation4, I’m just one signature away from admission, if the risk is high. As a doctor in a psychiatric emergency, I can admit you to a psychiatric hospital—in the state of New York—for up to 15 days before you’re allowed to see a judge. A second doctor will have to sign a document within 48 hours, but they usually do, if involuntary criteria are met.
In NYS, I can have you transferred to another hospital anywhere I would like, against your will, as long as I have more signatures. With those signatures, you don’t get to see a judge for 60 days. I can actually convert you to that involuntary legal status, which we call two physician certification, against your will. And I can do that after the emergency admission. It could be 75 days between the time you were brought into a psychiatric emergency room and subsequently admitted to a psychiatric hospital, no matter what you say, without you ever getting to see a judge and plead your case.
What I have just described may sound horrifying, but it’s what Eric Adams is proposing.
This Is a Bad Idea
Dude, I can’t begin to explain to you how bad this part of the plan is. It’s horrifying. And I am a psychiatrist who has dedicated my life to caring for the very humans we’re talking about forcing into “help.”
Involuntary care creates mistrust. It’s terrifying. It’s rarely helpful. At best, it’s going to lead to a lot of overworked emergency doctors. It will also lead to patients with even less trust in the police and healthcare than they already have. If you want to help homeless humans who are suffering, actually propose something that’s intended to help them. They will say YES if it’s understood as helpful!
The reason people don’t wanna go into a hospital voluntarily? Because it seems like a goddamn nightmare. Because it is often a goddamn nightmare.
Dear Eric Adams, and all policy makers: create helpful solutions! People will want those, voluntarily, without coercion.
—O. Scott Muir, M.D.
Frankly, I’m close to certain the Mayor’s order violates mental hygiene law in NYS. The Mayor is (most generously speaking) asserting that police should be able to transport people against their will, according to a legal standard below that of emergency admission standards…
For involuntary transport by police, the legal standard needed in the law as it stands has the following cases in which police can legally transport:
Emergency (§9.39)
Standard: Reasonable cause to believe that the person has a mental illness for which immediate observation, care and treatment in a hospital is appropriate and which is likely to result in serious harm to him/ herself or others. "Likelihood of serious harm" means:
A substantial risk of physical harm to the person as manifested by threats of or attempts at suicide or serious bodily harm or other conduct demonstrating that the person is dangerous to him/herself (See reverse #6), or
A substantial risk of physical harm to other persons as manifested by homicidal or other violent behavior by which others are placed in reasonable fear of serious physical harm.
If there is less likelihood of harm, 2 licensed MDs need to evaluate first, and sign off, and then request police transport on this lesser risk standard, but with more oversight:
Involuntary - Two Physician Certificate (§9.27)
Standard: Person has a mental illness for which care and treatment in a mental hospital is essential to his/her welfare; person's judgment is too impaired for him/her to understand the need for such care and treatment; as a result of his/her mental illness, the person poses a substantial threat of harm to self or others.
Now, it’s worth nothing that these are standards for admission to the hospital, not for being taken to the ER in the first place. But it’s hard to see how bringing someone in on a lower standard of risk and consent would be a good idea. It would mean that the people being brought by NYPD to the psych ER would be evaluated by doctors who would then be legally … UNABLE TO ADMIT THEM TO THE HOSPITAL ANYWAY.
Note to ACLU and Mental Health Legal Council: I do expert witness testimony. What I put in writing is a medical opinion, and has legal weight. I am hereby willing to provide forensic testimony as an expert witness against Eric Adams and the City of New York should they chose to enforce this decree. I don’t approve, and my medical license says I have a degree of expertise that you and your lawyers do not, were I called to testify to the standards of care, and if your law is in keeping with them. This article is also expressly encouraged to be used in any legal brief as a source of expert opinion.
In the context of strapping anyone down to a gurney, and injecting them with dysphoria inducing medications against their will, it’s worth noting side effects. These medications may induce an uncomfortable sensation of an inability to sit still, or remain motionless, which we call Akithisia. A person would be rendered completely unable to manage this by moving themselves, because they’d be strapped down, so they couldn’t move. If this sounds horrible, it’s because it really can be.