It’s time to treat mental illness in the ER with dignity

We doctors who specialize in psychiatry have a sacred trust. We are given the opportunity to talk to people who are hurting every day, people who trust that we will listen to them, try to understand them, not laugh at them, and not think that they are stupid, crazy, or horrible. A tall order, granted, given that we hear stories that sometimes border on the unimaginable, bizarre and otherworldly. This is a privilege. I believe that with all my heart, even on the days that I am the most busy and bone-tired and wondering why I chose to do what I do. My interaction with my patients, that sacred emotional bond between the hurting and the helping, is paramount. If we forfeit that, what do we really have to offer?

That being said, there is a horrendous breakdown in this trust between the hurting and the healing in the emergency departments where many mental health patients are forced by default to go for acute and  chronic care. We make jokes about the TSA and the indignity of passing through the obligatory minefield of airports large and small since 9-11, but the same indignities are being visited on the mentally ill of America every day.

When a person is picked up by the local sheriff’s department executing a probate court order for transport for mental health evaluation, one of the first things that often happens is that the patient is handcuffed. Keep in mind that this person has not been arrested or charged with any crime. They are simply being transported for a medical evaluation. I have heard patients with trauma histories talk about how they are triggered to the point of hysteria by this practice, as some of them have been bound, assaulted, even tortured in the past.

Can you imagine? You are scared, maybe strung out on drugs, already paranoid, and the police come to your front porch, seize you bodily, handcuff you, and put you in the back of a cruiser. This very first step, the very first contact with a system designed to help the mentally ill, scares some of these patients so badly that they never go back for treatment again.

This is only the beginning. When patients arrive at the ED, they are stripped of all personal possessions, clothing, jewelry, money, everything. No keeping an iPod that might be playing the very music that calms you and makes the voices fade into the background just enough to make them manageable. No keeping a Timex that might help you stay oriented during the next few days when you will be held in a nondescript room with no windows or clocks to help you know what time of day it is.

In some hospital EDs, personal health information is gathered and discussed in open cubicles or behind flimsy curtains that do little to address HIPAA regulations. The person next to you is having belly pain and is likely to have an appendectomy presently. You are hearing voices that tell you to kill yourself. Now everybody knows about both of you.

Security guards are used as sitters outside your door once you are committed for treatment. You can’t take walk down the hall to stretch your legs. You can only take a shower when allowed, and no razors are given to shave beards or legs. You can’t smoke, something that may not be in your best interest but that has strong implications among psychiatric patients. As my patient said last week, “this feels worse than prison, Doc”.

We talk about treating people with mental illnesses with compassion and gentleness. We talk about people being more than a diagnosis, more than a diagnostic code. More than just another case or “the bipolar in Bed 2”.

It’s time we start doing instead of talking. It’s time we start treating people who come to the emergency department for help with mental illness with dignity.

Greg Smith is a psychiatrist who blogs at gregsmithmd.

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