People With Mental Health Emergencies Deserve So Much More Than What Our Health-Care System Has to Offer

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Commentary Health Systems

People With Mental Health Emergencies Deserve So Much More Than What Our Health-Care System Has to Offer

Lynn Beisner

Too often, reaching out for help can mean being handed off to people who have absolutely no training in mental health care and who have deep prejudices against those with mental illnesses.

My mother did a brave thing, the thing that everyone says she should have done: She reached out for help when she was suicidal. She called me at 1:17 in the morning instead of using the gun she had been holding in her hand for hours. And I will always be grateful that she did.

However, I know with absolute certainty that if my mother faces the same choice again—call for help or stare down the barrel of a gun alone—she will not call for help. Because what followed that night in the emergency room was degrading, humiliating, and ultimately required her to face her worst demons, her greatest emotional pain, alone and under extremely stressful circumstances.

Any intervention that stops a person from acting on suicidal urges gives the people in their lives and professionals at least one more day to help the person in distress find the resources to live. Many people have found crisis phone lines, which are staffed with highly trained counselors, very helpful. While it is hard to study the effectiveness of suicide prevention hotlines, at least one study has indicated that they are effective in reducing a person’s immediate impulse to harm themselves, and that the benefit continues past the day of the contact.

But in the future, my mother is unlikely to use a suicide prevention hotline, because she is terrified of being engulfed by a system that has not served her well in the past. She believes that if she calls a hotline and does not comply with what the counselor suggests, the counselor will call local law enforcement.

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Police are usually the first responders to people having mental health emergencies. Since their training is primarily in threat assessment, this can and often does go horribly wrong, and mentally ill people end up being beaten, brutalized, or even killed.

In most areas, police have only two options: They can carry the mentally ill person to an emergency room or to prison. Neither of those options are particularly good for the patient, and both are extremely expensive.

To complicate matters, there is a national shortage of professionals who are qualified to help in psychiatric crises. Getting an emergency appointment with a psychiatrist without an emergency room is nearly impossible. In most cases, a person can expect to wait months for an initial consultation. Truly skilled practitioners are, perversely, more accessible. But only for those who can afford to pay out of pocket and hope that their insurance will reimburse them.

The reason for the shortage of psychiatrists is that mental health-care professionals are not paid at the same rate as other physicians. Combined with the stigma associated with mental illnesses, psychiatry has become a medical ghetto.

For a person experiencing a mental health crisis, the thought of seeking the sort of care that is generally recommended—initiating treatment through a mental health facility by going to an emergency room—can be daunting. The median wait time is just over eight hours for a psychiatric emergency, with the wait time increasing if patient has drugs or alcohol in their system, needs to be restrained, or needs non-psychiatric care. For people over 60 or for those without insurance (or other complications), the wait time increases by more than four hours. If there is not a bed available in the psychiatric ward of the hospital where the patient arrives, the wait time increases to a staggering 15 hours.

Emergency rooms are often not safe places for people in psychiatric distress. The environment itself, filled with anxiety and noise, is stressful. Once the patient has been assessed, there is very little ER personnel can do. The patient simply has to wait. During those intervening hours, the person’s distress can continue to build. They have plenty of time to reconsider their decision to seek help and to imagine how others will react. Staff rarely has the time to observe patients during this very distressing time, and some patients have killed themselves during the wait. In other cases, ER staff has released patients that were clearly still a danger to themselves or to others.

On the night that my mother nearly killed herself, I made a judgment call not to call 9-1-1. Instead, I stayed on the phone with her, telling her how much her family loved her as I blindly stumbled around trying to dress and find my keys and bag. My fingers went numb from panic, and my natural clumsiness escalated until I had the coordination and stealth of a rutting elephant.

Within minutes, the entire house was awake and every light was blazing. My daughter, who was 16 at the time, begged to be allowed to come with me. She rightly judged that she would be able to keep her grandmother calm and engaged while I drove.

When we got to my mother’s house, I took her hands and guided her into my car. “It is OK, Mom,” I told her. “You have had to change medications recently. We are just glad that you called.“

As I drove, I called the emergency number for my mother’s psychiatrist. When the doctor on call for the practice returned the call, I pulled over into the vast and empty parking lot of our local mall. We sat there in the island of a safety light, like the only survivors of some great shipwreck.

As soon as I answered, I put the phone on speaker. I didn’t want to talk about my mother like she wasn’t even in the car. But she could barely speak because she was working so hard at controlling the loud, heartbreaking sobs that kept bursting out of her.

The psychiatrist’s voice was clipped and brusque as he asked, “What is going on?” It was a question we would hear over and over that night.

“Never mind,” my mother said as she waved her hand. “I’m OK. Never mind.”

I did what I was told to do by the psychiatrist and took her to the local emergency room, where over and over we had to answer the same questions: Why was my mother depressed? Why did she have post-traumatic stress disorder? When was she sexually and physically abused? Had she sought care since then? Why did she stop treatment with one of the local psychiatrists? Why did she think it was a serious offense for a psychiatrist to open her mail and read it during the session? Is this an indication that she is easily angered?

The woman in billing casually asked in what year my mother was raped. Evidently, they needed that for the insurance forms. The technician who took her blood told her that God could solve her problems. The emergency doctor did not just telegraph his impatience in non-verbal ways—he actually told my mother that he did not have much time, that he had patients with serious medical conditions that required his care.

One image is burned into my brain from that night: It is of a respiratory therapist handing my mother a nebulizer. The therapist holds it in the tips of her fingers, as if she is afraid that physical contact with my mother will contaminate her.  Everything from the angle of her body to the look on her face conveyed disgust and contempt.

My daughter and I sat next to my mother’s ER bed as night gave way to morning, and morning stretched into afternoon. No one really talked to us. They collected medical data. But despite the obvious trauma for everyone involved, no one helped us process the experience. No one even said to my mother, “You did the right thing, calling your daughter. We are going to try to help you.”

As the day wore on, new medical personnel came on duty. We had to answer the same questions all over again. We got all new and often unsolicited opinions about how my mother could avoid becoming “bitter.” And as the hours ticked by in that cold room, it was like we all froze over.

My mother stopped crying and her eyes went vacant. She was fine now, she said, and she wanted to go home. Of course, no one would let her.

The longer it went on, the more impact the process of “getting help” for my mother had on how each of us made sense of what had happened. When they treated the person who had almost died from a heart attack so differently from how they had just treated her, a woman who had also almost just died, my mother got the distinct message that her illness made her less worthy.

And as each person passed through my mother’s door, we began seeing her through their eyes. When they did not treat her revelations with respect and kindness, it made us seem like saps or colluders when we did. Our relationship was irrevocably changed that day as we sat in the cold metal chairs waiting for my mother to be committed to a mental health unit.

After dinner, a nurse finally came to take my mother up to the hospital’s mental health unit. We gathered up our belongings to go with her, but we were stopped by the nurse’s upraised hand. We weren’t allowed to accompany her into the unit for some reason. It had been perfectly reasonable to leave her in our care for the previous 15 hours while we waited in the emergency room, but now we were cut off from her. She would have no telephone in her room, and we could not go and see her. She was essentially a prisoner.

The night after she had tried to commit suicide, my mother was left alone in a small room, unable to reach out to a single member of her family. According to what I was told, people brought into mental health wards are allowed contact with the outside world only during very limited times. She could only call during scheduled phone breaks. She was not allowed any phone privileges until the next day. What broke in her during that night of solitude has never been repaired.

Our relationship was changed as well. Seeing my mother through the eyes of medical professionals broke through my denial, and my belief that I could fix her. In the years that followed, our relationship deteriorated and recently it ended. While the changes in our relationship that started that day have been a positive thing for me, I know it has been very painful for my mother.

The truth is that reaching out for help can mean being handed off to people who have absolutely no training in mental health and have deep prejudices against those with mental illnesses.

The good news is that the psychiatric community understands that emergency rooms are not designed to serve the needs of people in a mental crisis, and are experimenting with various alternatives. In a few major cities, major hospitals have established separate psychiatric emergency rooms. Some privately run mental health hospitals have begun offering crisis treatment in places like “The Living Room” where mental health workers and peer counselors provide faster and cheaper care.

Sadly, funding for mental health services has been eviscerated. Between 2009 and 2012, $4 billion in aid to states for mental health care was cut from the federal budget, and more cuts are slated to follow. So widespread changes are likely to happen slowly, if at all.

In the meantime, the following resources may help people in psychiatric emergencies and their families navigate the system.

As a society, we need to seriously reconsider how we handle mental health care in general, and especially mental health emergencies. People who do a brave thing—those who put down the gun and pick up the phone—deserve to be treated with respect and compassion by qualified professionals. We may not be able to cure depression or end suicide, but we can start by treating people who are having mental health emergencies with humanity and understanding.