Why involuntary hospitalization cannot be the solution to violence
In cases like mine and too many others, civil commitment in psychiatric hospitals can cause damage outweighing any benefits.
Warning: This piece discusses anti-transgender discrimination, disordered eating, child protective services, foster care, suicide, psychiatric hospitalization, self-harm, abuse, and wrongful deaths.
Let me start by saying: Discussing mental health in the wake of mass shootings is a cop-out. Nonetheless, it’s now part of the picture, and the methods being advocated have serious downsides. Involuntary hospitalization isn’t the easy way out of providing comprehensive mental healthcare. If it’s part of the system at all, it must always be a last resort. After all, the act of removing a person in crisis from their familiar surroundings and limiting their contact with loved ones doesn’t seem conducive to mental stability.
This is a highly personal topic for me, and my community at large. I’m transgender — in the 2015 U.S. Trans Survey, two in five respondents had attempted suicide in their lifetime and around seven percent had attempted suicide in the past year. For comparison, the U.S. population overall has a lifetime suicide attempt rate of less than five percent, with only 0.6 percent attempting suicide in the past year.
Furthermore, survey respondents who had attempted suicide in the past year were less likely to receive medical attention. In the general population, three-fifths of those who’d attempted suicide received medical attention; 41 percent stayed in a hospital overnight. Just 45 percent of respondents received medical attention, and 30 percent stayed in a hospital overnight.
When I responded to this survey just after my 18th birthday in 2015, I was among those who’d attempted to take my life in the previous year. My suicidality had always straddled the line between serious ideation and attempting to take my life. For this reason, I only consider one of my episodes to have been an attempt. This was in November 2014, after I’d been hospitalized in May and twice in October. I didn’t go to the hospital in November.
The harsh realities of hospitalization
In December 2013, I suffered a concussion during water polo practice. The neurological disruption of the impact itself, combined with the social and academic challenges that followed, led to a diagnosis of depression just three months later. By the end of May 2014, I couldn’t cope. I was having serious suicidal thoughts with some concrete plans. My mom took me to the emergency room.
Mom stayed with me as long as she could, but I think we were also required to have a sitter in the room. Thankfully, it didn’t take too long for the social worker in the ER to find me a room at a nearby psychiatric hospital’s children and adolescents’ unit. I was transferred there in the middle of the night in an ambulance, strapped to the gurney with a security escort even though I’d been fully cooperative and shown no signs of aggression.
After I arrived at the hospital, the night nurse let me keep my stuffed animal. The next morning, though, the daytime nurse confiscated it and explained that we weren’t allowed to have comfort items from outside the hospital. They tried to comfort me with a mini stuffed animal from the children’s playroom. I pretended this was adequate.
Patients who misbehaved could be denied outdoor time — it was treated as a privilege, regardless of its therapeutic benefits.
I wasn’t out to anyone as transgender at that time, which made my situation easier. Girls’ bedrooms were in one hallway, while boys’ were in another. We weren’t allowed to walk down the wrong hallway without express permission. Shoes with laces were prohibited, and closed-toe shoes in general were only allowed when we went outside. We couldn’t have clothing with drawstrings, hard-cover books or standard pencils. All the pencils were half-length without erasers.
Thankfully, I had access to vegetarian meals there — but the only utensils we could use were plastic spoons. Staff counted the spoons they handed out and those they got back after a meal, and no one could leave the day room if any spoons were missing. Nurses would check how much each patient ate of each meal. If someone consistently failed to eat most of their food, they would be placed under closer watch during meal time. Some of these patients were required to stay in the day room for half an hour after they finished eating.
Most of the patients, myself included, were there on 5150s — the California code for involuntary psychiatric holds lasting up to 72 hours. A few were voluntary patients — they checked themselves into the hospital, usually within weeks to months of being on a 5150. In this facility, teenage patients didn’t have contact with younger patients. At age 16, I was on the older side but certainly not the oldest there.
Days in the hospital consisted mostly of individual and group therapy sessions. The schedule also included some time for arts and crafts, limited time outdoors under close supervision and down time we were expected to spend in our rooms. Patients who misbehaved could be denied outdoor time — it was treated as a privilege, regardless of its therapeutic benefits.
In group therapy sessions, we were dissuaded from sharing “war stories” — especially descriptions of self-harm or disordered eating behaviors. Staff could decide what was and wasn’t appropriate. Though the sessions were nominally voluntary, staff assumed that patients who didn’t attend weren’t fully committed to their recovery. As an Autistic person who was undiagnosed at the time, I struggled to deal with these apparent contradictions and ambiguous rules. Still, I spent longer than the required 72 hours in the facility because I didn’t feel I would be safe going home after the hold ended.
When leaving the hospital isn’t the end of the story
I left the hospital the weekend after I entered. By then, I was enrolled in a partial hospitalization program through the same hospital, scheduled to start the following Monday. For two weeks, I spent eight hours per day just two floors below the inpatient unit. I found this much more helpful than the involuntary hold — I could go home in the evenings, and my family was more integrated into my treatment. We had more freedom to discuss our real lives, though some boundaries remained.
Unfortunately, my recovery was far from a straight path upward. During my first hospitalization, my hospital-assigned psychiatrist prescribed a very low dose of Abilify to help stabilize my mood. It helped — but the side effects ultimately became unbearable. Just weeks after starting the medication, I went to the ER for severe abdominal pain. The doctor ordered a CT scan to screen for appendicitis. The real cause was severe constipation, so Miralax was added to my medication list. By late August, my balance was impaired and I experienced regular dizzy spells.
Over the phone, my outpatient psychiatrist recommended I stop the Abilify. I was still on a very low dose — just half a milligram — so tapering seemed logistically challenging and medically unnecessary. This, it turns out, was a bad call. My mood plummeted and my self-destructive urges returned; within a month, my mom and I decided I needed to go to the ER again for my own safety.
This time, it took a full day and a half for a pediatric bed to open up at any of the nearby psychiatric hospitals. I spent that time in the emergency department — for a time, I was moved to the casting room with another psychiatric patient waiting for a bed. The individual rooms were needed for other patients. My mom spent as much time as possible with me, sometimes coordinating with my dad and stepmom so she could take care of her other responsibilities while they visited.
By then, I was openly transgender. My mom talked to the social worker and tried to make sure I would be placed with boys. They couldn’t do this, so she negotiated for a single room on the girls’ side. She also tried to make sure I would have adequate food options given my vegetarian diet. Despite the social worker’s assurances, many of these requests were either inadequately communicated or wholly ignored.
Fighting a war on two fronts: internal and external
The first available inpatient bed was just a few floors above the emergency department, but I was still brought there in a wheelchair with a security escort. There, I was allowed to keep my stuffed animal, and the staff let my mom bring my pillow from home. I appreciated these allowances, but they didn’t make up for the hospital’s numerous failures. It took them days to even realize I was a vegetarian, not being stubborn or eating in a disordered way when I refused any of the meat-based entrees on the daily menus.
The food problems, while significant, were the least of my worries. I was placed in a room deep within the girls’ hallway, with a female roommate. Every morning, I would erase my legal name from the whiteboard outside my door along with the quotations surrounding my real name. I hadn’t legally changed my name yet, but that didn’t give them a right to misgender me in such a public way for everyone to see.
These efforts were futile, but they were a way for me to assert my identity. The whiteboard was something I could at least try to control, far more than I could control the nurses who called me by my birth name every morning for vitals. Somehow, I found myself battling both my mental illness and the hospital’s insensitive staff. I coped by spending a lot of time either in my room, playing hundreds of variations of solitaire with real cards, or playing Monopoly with younger patients in the day room.
In that unit, children and adolescents were not separated. The youngest patient was probably in second or third grade. I think at least one of the younger “patients” there wasn’t actually in crisis internally — rather, the hospital was a place to stay while their social worker and CPS tried to arrange a foster placement. But there were patients in active internal crises, and on at least one occasion a patient tried to escape.
Early in this hospitalization, I noticed something peculiar. Two of the patients weren’t verbally responding to any of the staff. One of them wrote me a note after he heard me correct a nurse who misgendered me. It was a short message, along the lines of “are you trans?”. I was a little hesitant to respond at first, but then I realized a pre-teen he hung out with was in the habit of correcting nurses who misgendered him. He wasn’t judging me — he wanted to know if I was like him. I wrote “Yes.”
I almost felt guilty for leaving him to fend for himself when I was ready to be discharged.
Over the following days, I learned that he had been there for weeks. After a few days, he’d stopped responding to staff in protest. He was also placed in the girls’ hallway, with a female roommate. We communicated as often as we could, writing notes on paper when indoors or using chalk when outdoors. I started correcting staff when they misgendered him, and he gave staff nasty looks when they misgendered me. When his roommate was discharged, I was transferred into his room.
My mood began to stabilize while I was his roommate. He didn’t talk even when we were alone, but we had other ways to communicate. During scheduled quiet time, he showed me how to climb up the shelves in the corner of the bedroom to read all the messages left by patients who’d long been discharged. One night, we had a pillow fight — which got both of us in trouble, but gave me a taste of genuine joy for the first time in days.
I almost felt guilty for leaving him to fend for himself when I was ready to be discharged. He told me they were trying to find a residential facility for him, because he had been in the hospital for much longer than most patients but he wasn’t stable enough to be discharged. Though I hoped they’d be able to find a facility that could meet his needs, I knew it wasn’t likely. I had a loving and supportive home to return to — from what I could gather, he didn’t. There was no way to keep in touch with other patients after being discharged — I’ll never know what happened to him.
I pretended to be better than I was, because I couldn’t handle being there anymore.
Within a week of being discharged, my self-destructive behaviors and urges were worse than ever. Even though I’d started attending the partial hospitalization program again, I couldn’t hold myself together. I admitted to one of my providers in the program that I was hurting myself again. The order of events in my memory is fuzzy, but I somehow ended up back in the emergency room.
The second hospitalization is a blur. I remember trying to hurt myself with whatever I could get my hands on — which wasn’t much. I pretended to be better than I was, because I couldn’t handle being there anymore. The other trans patient had been discharged by the time I returned. As I was one of the oldest patients in the unit, I tried to adopt the role of older sibling — I played all sorts of board games and card games with younger patients. This, combined with my participation in group and individual therapy and my safety planning, convinced my psychiatrist to discharge me.
Dealing with the fallout is (at least) half the battle
Between the two back-to-back hospitalizations, I missed a month of school. My teachers agreed to let me catch up over winter break — but there was nothing I could do to repair my social life. The friends I’d had before the hospitalization tried to support me for the first couple of weeks, but eventually they got tired of my constant “negativity”.
The night my friends stopped talking to me, I became extremely distraught. This, in November 2014, precipitated my one serious attempt to take my life. Halfway through, I stopped myself and told my mom what I’d done. We assessed the damage and decided I didn’t need medical attention. The conversation turned to whether I needed to be hospitalized again.
By that time, Mom understood that the hospital wasn’t helping me. I’d just started a 12 week-long intensive outpatient program, which I could do while still going to school. Removing me from my community again seemed like a bad decision — so I didn’t go back. I haven’t hurt myself since that night. Even when my then-boyfriend broke up with me on New Year’s Eve less than two months later, even when I was sexually assaulted and had to leave my university, I didn’t hurt myself again.
People like me are the lucky ones
I was, comparatively, a “good” patient. Even though I pretended to be better than I was to get out of the hospital, my behavior was generally under control. I didn’t cause much trouble beyond standing up for myself when I was misgendered. But the hospital still didn’t help me get much better — it only temporarily prevented me from hurting myself.
If I hadn’t stopped myself mid-attempt, my story would have been disturbingly similar to one that played out just six months later. In early April 2015, Kyler Prescott, one of my friends from the LGBT youth center’s trans discussion group, was hospitalized. He was placed in the same hospital I’d been in the previous fall, and the staff treated him much like they’d treated me. Even though his mom advocated for him vigorously, nothing changed — the unit even blocked her number because her advocacy was so persistent. Ms. Prescott eventually sought to have his 5150 hold lifted early, and it was — Kyler spent just one day in the unit.
Six weeks after his hospitalization, a few of my other friends from the center and I attended Kyler’s memorial service. He was 14 years old, three years younger than me. With help from a few LGBT legal advocacy organizations, Ms. Prescott filed a lawsuit against the hospital for unlawful sex-based discrimination and false advertising two years after his death.
This tragedy does not stand alone. Inpatient psychiatric hospitals are routinely sued for a myriad of offenses, including wrongful deaths. Here are just a few recent, high-profile cases involving inpatient psychiatric hospitals:
- March 2017: A teenage patient voluntarily checked herself into a psychiatric hospital in Texas. The next day, she requested to be discharged. Staff told her she would be placed on an involuntary 24-hour hold if she tried to voluntarily discharge herself, and repeatedly refused to discharge her even after she’d completed the necessary paperwork.
- January 2018: Two lawsuits were filed by women who’d been held against their will at a Texas psychiatric hospital. Each had gone to the facility seeking information on outpatient services, only to be placed in inpatient care for 24 to 43 hours.
- November 2018: A jury awarded $250,000 to each of 371 former patients of a state-run psychiatric hospital in Nevada. They had been bused out of the state and left there with no follow-up care or housing, leading many to be arrested, re-hospitalized, or to become homeless.
- December 2018: After a ProPublica investigation, a class-action lawsuit was filed against the Illinois Department of Children and Family Services. Between 2015 and 2017, children in DCFS care had been unnecessarily held in psychiatric hospitals for a total of 27,000 days.
- January 2019: A patient in the care of the South Carolina Department of Mental Health died by suffocating at the bottom of a dogpile of employees. This technique was expressly prohibited in staff training, yet this death still occurred.
- March 2019: A patient died in a New Jersey psychiatric hospital after collapsing on the floor. Staff failed to perform CPR for a full eight minutes after her collapse. Another patient who witnessed the death was not provided adequate psychological support or counseling to cope with the trauma.
- July 2019: A woman in her 80s joined a class-action lawsuit against a New Jersey psychiatric hospital. She was physically and sexually assaulted by staff during her 3½ year hospitalization, which began with an involuntary commitment. Even though her daughter fought for her release and hired attorneys, she was only released due to “overcrowding”. Her psychiatric and physical health both deteriorated during her hospitalization.
Think about what can happen to patients in these hospitals, those who are a danger to no one but themselves, if we start using them to warehouse anyone with violent tendencies.
If we’re going to have a discussion about mental healthcare, we need to talk about all of it. The ugly parts will only get uglier if we ignore them and treat involuntary hospitalization as a catch-all solution for those who want to hurt themselves or others. The practice is ethically questionable practice and only appropriate in the most extreme circumstances. Other parts of the mental healthcare system must be strengthened. Any viable alternatives to hospitalization must be part of the picture.
Please, if nothing else, think about people like me before you advocate involuntary hospitalization as a way to deal with violent people. Think about what can happen to patients in these hospitals, those who are a danger to no one but themselves, if we start using them to warehouse anyone with violent tendencies. Consider the potentially-traumatic memories you invoke when you have these conversations. Remember that psychiatric patients are people, too — unless something tragic happens, we have lives after hospitalization.