ima4ltrwrd

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We had a patient come in to a community based crisis center voluntarily to get resources. He wanted to get help for symptoms of depression and anger. He agreed to come in for a 23 hour admission for evaluation but immediately after he was admitted he changed his mind and asked to leave. We attempted to talk him into staying but he declined. He did not want to undergo an evaluation prior to leaving. He was willing to let us contact a significant other who basically said please don't let him go and that he is going to have a meltdown soon which will likely end up with something bad happening to himself or someone else. He was described by collateral as violent, aggressive, and impulsive. When asked directly, there was no stated threat towards the collateral however the impression from the social worker was that there was some hesitance to directly report a threat (ie no he hasnt threatened me but please please dont let him go). He had recently gotten into a fist fight with stranger. He had recently been released from prison on a 15+ year sentence for attempted murder. He has made several suicide attempts in the past. He was mostly pleasant during our encounter but very guarded and evasive. He never made any reference that he was a having thoughts of ending his life, nor harming other people; only acknowledging he was feeling depressed and angry. He demonstrated no obvious psychotic symptoms nor manic symptoms. The general consensus from our staff was that they all had a bad feeling about this guy. At that point we had a discussion about what to do and I generally was of the thought that while I believe this guy to be high risk, I had no grounds to pursue involuntary commitment. I was told by one of our senior staff that there was a degree of implied danger to self and others that would justify commitment. I was also told that it's these individuals, who are so guarded, evasive, and reluctant to engage in interview, that we need to be most concerned about. While I agree with this sentiment, I struggle to understand how we can do this within the scope of the law. I certainly could have committed him out of an abundance of concern for his safety and the safety of the public likely without any legal ramifications. I would argue my action on his history of past violence, escalating incidences of violence preceding his visit, and the testimony of the collateral. My risk assessment would demonstrate numerous risk factors, with almost no protective factors. I would argue that he lacks insight and demonstrated poor judgment at the time of admission. Despite this, I do not know if I could argue that an actual danger exists.

My question is what are peoples thoughts on the "implied" danger and reading in between the lines when dealing with involuntary admission? Conversely, lets say I did I let him go and he did kill himself or someone else. Could the implied danger be used against me (I would assume this would be the crux of the case..."Dr. couldn't you see the writing on the wall!") even though he never uttered a specific word about danger to self or others to define an actual risk? The law where I am states that there has to be an immediate threat towards the self or others in order to start the involuntary commitment process.

What would you have done in this case? Lets discuss.
 

F0nzie

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If the pt denies SI/HI with absence of observational evidence for DTS and DTO (suicide letter, cutting self, harming another) I do not think involuntarily commitment is warranted regardless of how many risk factors are present. Voluntarily seeking resources is a protective factor so there is that. Also if you did not witness a particular event you can always suggest that the witness file the petition themselves.


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splik

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I will preface this by saying that I take individual liberty very seriously and have a very high bar for depriving someone of their liberty. Also civil commitment laws do vary significantly from state to state (for example where I was before psychiatrists didnt have the power to commit anyone, whereas where I am now you can get committed for anything). However in general, the burden of proof for initiating a hold on a patient is probable cause (i.e. pretty low).

In this case you have someone who is ambivalent about assessment, comes in and then wants to leave, has anger as one his presenting complaints, is guarded, has a significant other begging you not to release him and noting that he is "violent, aggressive and impulsive", and recent violent behavior, as well as a history of attempted murder and multiple suicide attempts. Clinically, everyone "has a bad feeling" (which imho cannot be overestimated - countertransference is the most useful tool we have for clinical risk assessment). I am, quite frankly amazed that you have come to the conclusion that you had no grounds to pursue involuntary commitment. As mentioned the standard is usually fairly low, you only need probable cause. If something were to happen, a jury would not take too kindly to you having ignored the significant other begging you not to discharge him. At the very least, you could conduct your evaluation on the commitment, and if you decide that you're not worried, let him go.

Also the statement "I believe this guy to be at high risk" in the context of him declining evaluation is grounds for commitment.

The issue at hand though is if this risk due to a mental disorder? Being an antisocial jerk is not a mental disorder. we do not have a duty to deal with individuals who are dangerous in the absence of mental disorder.

I really do not understand what you mean by implied danger vs actual danger. When we are talking about violence risk it's always implied.

Voluntarily seeking resources is a protective factor so there is that. Also if you did not witness a particular event you can always suggest that the witness file the petition themselves.
There is no protective factor if the person is guarded and refuses to speak further to you and is asking to leave. quite the opposite.
 

clausewitz2

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I will preface this by saying that I take individual liberty very seriously and have a very high bar for depriving someone of their liberty. Also civil commitment laws do vary significantly from state to state (for example where I was before psychiatrists didnt have the power to commit anyone, whereas where I am now you can get committed for anything). However in general, the burden of proof for initiating a hold on a patient is probable cause (i.e. pretty low).

In this case you have someone who is ambivalent about assessment, comes in and then wants to leave, has anger as one his presenting complaints, is guarded, has a significant other begging you not to release him and noting that he is "violent, aggressive and impulsive", and recent violent behavior, as well as a history of attempted murder and multiple suicide attempts. Clinically, everyone "has a bad feeling" (which imho cannot be overestimated - countertransference is the most useful tool we have for clinical risk assessment). I am, quite frankly amazed that you have come to the conclusion that you had no grounds to pursue involuntary commitment. As mentioned the standard is usually fairly low, you only need probable cause. If something were to happen, a jury would not take too kindly to you having ignored the significant other begging you not to discharge him. At the very least, you could conduct your evaluation on the commitment, and if you decide that you're not worried, let him go.

Also the statement "I believe this guy to be at high risk" in the context of him declining evaluation is grounds for commitment.

The issue at hand though is if this risk due to a mental disorder? Being an antisocial jerk is not a mental disorder. we do not have a duty to deal with individuals who are dangerous in the absence of mental disorder.

I really do not understand what you mean by implied danger vs actual danger. When we are talking about violence risk it's always implied.


There is no protective factor if the person is guarded and refuses to speak further to you and is asking to leave. quite the opposite.
If it weren't for the fistfight, there would be no grounds in my state in principle, since si/hi with an act of furtherance that was directly observed in the past thirty days is required. Simply stating intent is insufficient, and history beyond thirty days is (supposed to be) irrelevant.
 

Jules A

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Based on what you describe, in my state and hospital there is no way I'd have let this patient leave. Most of the time myself or staff is able to convince someone in this situation especially because he isn't psychotic that signing in voluntarily is the way to roll. I usually approach it like this "man it sounds like you really have a lot on your plate right now, I'd appreciate the opportunity so see if there are services and or medication that might be helpful for you because I can tell you really don't feel well or you wouldn't have come in for assistance. You made an excellent decision to come for help and many people don't realize that anger absolutely can be a sign of depression which is unlikely to go away without treatment. I'd urge you to sign in voluntarily so we can spend a few days getting to know you and trying to help you feel better. If you decide to sign in and change your mind you are able to sign a 72h notice of your intent to leave and trust me we don't keep anyone for longer than they need for basic stabilization". Worth noting I always explain the 72 in full and never skirt around that like I know some ED workers will in an effort to make a patient sign which of course is illegal as well as causing huge problems for the patient and unit staff when they arrive, realize they can't just request to go home and subsequently flip out. If they continue to refuse I will outline the reasons I will be required to certify them and would straight out tell him that if he isn't willing to sign in voluntarily I will in fact be certing him. If this causes him to flip, there ya go, if not often times at that point another staff member like a kindly social worker can talk them into signing the voluntary.
 

milesed

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Jules,

What state are you in? In my state, you can't hold someone unless the SI/HI threat has been made or there is sufficient evidence for either
 
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ima4ltrwrd

ima4ltrwrd

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Thanks for everyone's comments thus far. I agree that there are significant risk factors present however little/no observational evidence of imminent danger which is why I was asking about the implied vs actual danger. Like splik mentioned, the threat of violence is implied, unless there is an actual threat. This patient has lots of red flags that suggest potential for, but not an imminent danger. Actual danger, for which it sounds is not a real or legal term, in my mind is based on the observed recent behaviors or actions to support evidence of imminent danger. Like f0nzie mentioned these would be if the patient is threatening self, engaging in para suicidal behaviors/gestures, observed making threats, is volatile emotionally/physically, walking around with a weapon, or acquiring a weapon, etc. These are observable examples in which one could argue intent or imminence. Again, this patient seemed to border on the edge of these concerns. I agree the recent fight would be the most observable evidence for imminence. Another good point splik made was whether or not this was a mental disorder, again without the proper evaluation, it was difficult to tell but antisocial pd was high on my list. Either way, the point was to start a discussion and to get other peoples opinions so thank you to everyone for engaging. We ended up proceeding with the commitment in case anyone is wondering.
 

slappy

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I will preface this by saying that I take individual liberty very seriously and have a very high bar for depriving someone of their liberty. Also civil commitment laws do vary significantly from state to state (for example where I was before psychiatrists didnt have the power to commit anyone, whereas where I am now you can get committed for anything). However in general, the burden of proof for initiating a hold on a patient is probable cause (i.e. pretty low).

In this case you have someone who is ambivalent about assessment, comes in and then wants to leave, has anger as one his presenting complaints, is guarded, has a significant other begging you not to release him and noting that he is "violent, aggressive and impulsive", and recent violent behavior, as well as a history of attempted murder and multiple suicide attempts. Clinically, everyone "has a bad feeling" (which imho cannot be overestimated - countertransference is the most useful tool we have for clinical risk assessment). I am, quite frankly amazed that you have come to the conclusion that you had no grounds to pursue involuntary commitment. As mentioned the standard is usually fairly low, you only need probable cause. If something were to happen, a jury would not take too kindly to you having ignored the significant other begging you not to discharge him. At the very least, you could conduct your evaluation on the commitment, and if you decide that you're not worried, let him go.

Also the statement "I believe this guy to be at high risk" in the context of him declining evaluation is grounds for commitment.

The issue at hand though is if this risk due to a mental disorder? Being an antisocial jerk is not a mental disorder. we do not have a duty to deal with individuals who are dangerous in the absence of mental disorder.

I really do not understand what you mean by implied danger vs actual danger. When we are talking about violence risk it's always implied.


There is no protective factor if the person is guarded and refuses to speak further to you and is asking to leave. quite the opposite.
Agree with this post, with the clarification that "probable cause" is defined differently in different states -- i.e. the bar for finding probable cause for commitment is different in different regions of the country (instead of the term "probable cause" itself implying a low burden of proof). However that is a matter for the legal system, not the physician.
 
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wolfvgang22

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I probably would have placed him on a hold. The judge has to agree, you are just making a recommendation to the court when you fill out legal psychiatric hold papers. If the judge does agree, the patient then gets evaluated by at least one other psychiatrist in most states before the patient can be held more than 48 to 72 hours depending on the state. They then have to file for linger commitment if needed, which again must be approved by the court.
 
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sunlioness

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Involuntary commitment is a violation of an individual's civil rights. Which isn't to say it doesn't have a place. For me, I need to be damn sure that the threat is imminent and not a "well, maybe..."

I'd send him out and document the crap out of it.


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nexus73

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In general the bar for placing someone on a hold is extremely low. As far as "legal requirements" for placing a hold, I know in my state there are no repercussions to me unless it can be proved I acted in a grossly negligent manner in placing the hold, which would be very difficult to prove in a case like the OPs, in which the patient sounds extremely high risk.

At the end of the day if I'm not convinced the person is going to be safe I can put them on a hold and let the legal system decide if the person can be committed or not.
 
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michaelrack

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IN my primary state (MS); I would put the patient on a 72 hour hold, and then if the patient still wanted to leave after 72 hours, depending on the circumstance would 1) do a regular discharge, 2) file for commitment or try to get family to file, or 3) discharge AMA, documenting that although I had concerns, I did not have enough direct evidence to have the hospital file for commitment.ld
 
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Jules A

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Jules,

What state are you in? In my state, you can't hold someone unless the SI/HI threat has been made or there is sufficient evidence for either
Maryland. There is no longer a mention of imminent. Although like I said in most cases except with the floridly psychotic we encourage them to sign in voluntarily.
 

SeniorWrangler

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Probably antisocial, high likelihood of violence. If you work in a state where a mental health professional decides about involuntary admissions, I'd probably refer him.
 

PistolPete

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Sounds like ASPD to me. I probably would have discharged also. This definitely does not sound like a cut and dry case, and you could argue it either way. In Florida, the standard is more strict than in other states, it seems. Since he has not verbalized wanting to kill himself, harm anyone specific, and doesn't appear to be gravely disabled as a result of mental illness (i.e. he can still find clothing, food and shelter), you really have no grounds to hold him.

However if you were to have put him on a 72 hour hold, I don't think anyone would really fault you and nothing would really come of that (i.e. he couldn't sue you later for it as long as you appropriately document the collateral's concerns, his risk factors and your concerns).
 
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Not too surprising that someone who is newly released from prison after a 15 year sentence for attempted murder is depressed, angry, guarded, and raises the hackles of staff. The bigger question is what happens after the hold because most of this guy's problems are likely psycho-social and our mental health system isn't really set up for folks like him.
 

clausewitz2

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Not too surprising that someone who is newly released from prison after a 15 year sentence for attempted murder is depressed, angry, guarded, and raises the hackles of staff. The bigger question is what happens after the hold because most of this guy's problems are likely psycho-social and our mental health system isn't really set up for folks like him.
A hold at this point I feel also guarantees he will never, ever voluntarily present for treatment in this system again. Some people may not see this as entirely negative.
 

Ceke2002

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A hold at this point I feel also guarantees he will never, ever voluntarily present for treatment in this system again. Some people may not see this as entirely negative.
Different circumstance, but I have a friend who's currently in this position and it's ended up becoming a real catch 22 situation. Chronic and severe presentation of AN (purging subtype), she does at least stay in contact with her treatment team, but almost continuously refuses to engage in any sort of actual treatment program or suggestions, which means inevitably she ends up becoming medically unstable to the point that she ends up being sectioned just to save her life, but sectioning also leads her to become extremely mistrustful of engaging in any sort of treatment voluntarily for fear she'll end up being sectioned again once released, which in turn means she will end up being sectioned again because she steadfastly refuses any sort of voluntary treatment options that might at least keep her medically stable enough to stay out of hospital - and the cycle just keeps continuing over and over. Of course it's difficult for those around her as well, including her treatment team I would presume, because none of us actually wants to see her die, and it's not like she ever ends up under a section just on a whim, but at the same time sectioning her isn't helping in the long run either. And it's not like we can't see the section coming a mile off, but trying to talk to her and convince her to please except a small level of voluntary treatment so she can at least stay out of hospital is like talking to a brick wall sometimes. I don't envy whoever has to make the call to detain her in the first place, especially when they probably know damn well once she's off section it'll be 6 months to a year, if they're lucky, before they have to section her all over again.
 

Jules A

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A hold at this point I feel also guarantees he will never, ever voluntarily present for treatment in this system again. Some people may not see this as entirely negative.
Or if as I've seen he will decide its not a bad place to spend the weekend and will be back to our ED seeking voluntary admission for vague SI or HI in the future for respite care. I wonder what they expect to happen when presenting to the ED with this type of complaint.
 
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Jules A

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Not too surprising that someone who is newly released from prison after a 15 year sentence for attempted murder is depressed, angry, guarded, and raises the hackles of staff. The bigger question is what happens after the hold because most of this guy's problems are likely psycho-social and our mental health system isn't really set up for folks like him.
Absolutely and hopefully as is the case at the facilities where I work unless the person continually refuses there are out patient services for mental health, housing etc. that our social work team can put into place so not always a complete waste of everyone's time. Hopefully this patient was of the narcissistic flavor who thinks he's brilliant and charming and held up that facade during the hold rather than being miserably unpleasant to everyone.
 
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Absolutely and hopefully as is the case at the facilities where I work unless the person continually refuses there are out patient services for mental health, housing etc. that our social work team can put into place so not always a complete waste of everyone's time. Hopefully this patient was of the narcissistic flavor who thinks he's brilliant and charming and held up that facade during the hold rather than being miserably unpleasant to everyone.
You're missing the point, which was that the guy probably doesn't even have a mental illness so a system that presumes problems are caused by a mental illness will not help and will actually make things worse. The whole concept of Antisocial Personality Disorder and its inclusion in our diagnostic manual is horribly flawed if you ask me. Aggressive and violent behavior is not a mental disorder. It is actually quite the opposite. Freud said aomething about the thin veneer of civilization covering up our aggressive impulses. I think he was right on the money with that concept. I would argue that we, i.e, people who work in mental health, are the outliers with our empathy and sensitivity and minimal aggressiveness.
 

Jules A

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You're missing the point, which was that the guy probably doesn't even have a mental illness so a system that presumes problems are caused by a mental illness will not help and will actually make things worse. The whole concept of Antisocial Personality Disorder and its inclusion in our diagnostic manual is horribly flawed if you ask me. Aggressive and violent behavior is not a mental disorder. It is actually quite the opposite. Freud said aomething about the thin veneer of civilization covering up our aggressive impulses. I think he was right on the money with that concept. I would argue that we, i.e, people who work in mental health, are the outliers with our empathy and sensitivity and minimal aggressiveness.
Hopefully I didn't miss your point as I agree with what you have written and in a perfect world I wouldn't have anyone other than patients with true acute Axis I disorders on my units but I do think these admissions can benefit both the person with ASPD who came in for assistance as well as our community even if only briefly. The patient in the OP of course rescinded his willingness to be admitted so he will probably get no more benefit than me covering my butt should he go out and do something dangerous if I released him without an admission. There are also many who present to the ED insisting they are SI or HI and are considered for admission because the assessment team staff and ED physicians feel their hands are tied. Some times I'll take them rather than risk alienating my ED team or calling the patient's bluff and having them up the ante. Unfortunately in my area the fact is we often get ASPD patients who were recently released from corrections with poor personal supports and no social skills whatsoever who I believe might also benefit from a weekend of shelter, meals and a social work consult to possibly give them additional outpatient resources. They are also usually on a crap ton of meds from the correctional facilities for their "bipolar" which further solidifies the admission. Flawed logic perhaps but why I might arrive from point A to B in these cases I guess.
 
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nexus73

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People can have aspd and be depressed, anxious, and have ptsd. And the homicidal thoughts might resolve with treatment of these latter conditions.
 
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ima4ltrwrd

ima4ltrwrd

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A hold at this point I feel also guarantees he will never, ever voluntarily present for treatment in this system again. Some people may not see this as entirely negative.
That was my primary concern tbh.
 

splik

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A hold at this point I feel also guarantees he will never, ever voluntarily present for treatment in this system again. Some people may not see this as entirely negative.
spoken like a true rookie. this is exactly how i thought when i was a neophyte resident. it is certainly true the majority of the time, but a not insignificant minority of patients are actually grateful for having been deprived of their liberty or forcibly drugged. when someone presents voluntarily and then changes their mind, there is often significant ambivalence and it can be not only necessary but helpful to take the decision out of their hands. sometimes that can be a great relief. When I was an intern I refused to write an order to forcibly drug a non-dangerous geriatric patient who was declining antipsychotics for mania (a decision that had me marked out as trouble all throughout residency), feeling responsible for her, thinking this would prevent her from seeking help again, and wouldn't be helpful. When the patient was discharged (despite the horrendous ordeal for being held down and forcibly drugged) she said to me "you know that medicine wasn't so bad, i think it's helped me." (I wasn't her psychiatrist at this point I just happened to see her and was shocked!) I can think of several patients who were later glad to have been involuntarily detained. never say never
 
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ima4ltrwrd

ima4ltrwrd

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spoken like a true rookie. this is exactly how i thought when i was a neophyte resident. it is certainly true the majority of the time, but a not insignificant minority of patients are actually grateful for having been deprived of their liberty or forcibly drugged. when someone presents voluntarily and then changes their mind, there is often significant ambivalence and it can be not only necessary but helpful to take the decision out of their hands. sometimes that can be a great relief. When I was an intern I refused to write an order to forcibly drug a non-dangerous geriatric patient who was declining antipsychotics for mania (a decision that had me marked out as trouble all throughout residency), feeling responsible for her, thinking this would prevent her from seeking help again, and wouldn't be helpful. When the patient was discharged (despite the horrendous ordeal for being held down and forcibly drugged) she said to me "you know that medicine wasn't so bad, i think it's helped me." (I wasn't her psychiatrist at this point I just happened to see her and was shocked!) I can think of several patients who were later glad to have been involuntarily detained. never say never
I dont see what is naive about having that concern, especially for THIS patient. He has been institutionalized for most of his adult life, he has little understanding of how the system works (he walked into a crisis center to presumably get outpatient services), and when he attempted to enter the system he had his rights suspended. If his first attempt at getting help was anything remotely reminiscent of prison then he most certainly wont try it again. It's not a similar comparison with people who are manic or psychotic, which is why I disagree with you in this situation. Otherwise, yes there are some people who benefit from imposing your will on them while they are temporarily incapacitated by their illness, but those in my experience have been few.
 
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Jules A

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I dont see what is naive about having that concern, especially for THIS patient. He has been institutionalized for most of his adult life, he has little understanding of how the system works (he walked into a crisis center to presumably get outpatient services), and when he attempted to enter the system he had his rights suspended. If his first attempt at getting help was anything remotely reminiscent of prison then he most certainly wont try it again. It's not a similar comparison with people who are manic or psychotic, which is why I disagree with you in this situation. Otherwise, yes there are some people who benefit from imposing your will on them while they are temporarily incapacitated by their illness, but those in my experience have been few.
Although generally speaking as of course I don't know the particular patient in question in my experience the antisocial post-incarceration patients I have cared for are not in any way, shape or form traumatized by being hospitalized on an inpatient unit for a couple of days while we gather more data to ensure they are safe and provide them with outpatient resources. They are usually savvy and know going into the ED the likelihood of being held if they verbalize SI or HI. Like you mentioned they are institutionalized and in most cases they actually do well and recompensate quickly in the acute mental health unit setting because it is comfortable, safe and all of their needs are being met in a less restrictive environment than they are accustomed to in jail or prison. A few leave pissed off but again just anecdotally the cluster B patients I have encountered will not hesitate to return to my ED in the future and demand whatever it is they feel will meet their needs at the time.
 

RichterBelmont

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In CA, statements that can be legally used by a psychiatrist to justify an involuntary hold are statements made by the patient (obviously), or family.
If it was a significant other relating a story of recent violence, past history of violence and incarceration, previous suicide attempts, impulsive behavior, I would have probably put him on a hold, especially since the person presented with depression and angry and REQUESTED evaluation and stabilization.