END PROLONGED SOLITARY CONFINEMENT by Dr. Mariposa McCall, Psychiatrist

On February 8, 2018, I along with Dr. Everett Allen (an internist who worked for several years at California Pelican Bay State Prison's solitary confinement), Cyrus Ahalt (a UCSF Public Health and Criminal Justice researcher), and Steven Czifra (a UC Berkeley MSW intern who was confined in solitary confinement for eight years while in juvenile then adult corrections facilities), presented on the relevance of solitary confinement to community mental health at the California Contra Costa County Psychiatry and Psychology monthly meeting.

Solitary confinement is being held in a small cell for 22 to 24 hours a day with minimal property and no meaningful human contact. We reviewed the physical and psychological harms of this most restrictive housing placement. In addition, we explored the dual loyalties for providers as they participate in this practice. As providers, is it ethical to declare someone fit for this high risk containment? This is what is happening — we are witnesses and participants.

Canada's Supreme Court declared solitary confinement unconstitutional in January 2018. A few months later, India, too, acknowledged this preventable harm. When will this nation reach this decision? On any given day in the USA, 100,000 are held in these extreme conditions, some unconscionably for years and decades. Fifty percent of suicides occur in these restrictive segregations, and self injurious behaviors are rampant.

This is preventable. We, as providers, will see these individuals as patients when released. Ninety-five percent of those incarcerated will be released. As community members, we will walk, shop, eat, live with them. Do we want traumatized or rehabilitated individuals? Some of you may feel this issue does not pertain to you, but ethical guidelines of "first do no harm" and human rights concern us all.

I am hoping you will join me in signing the petition I wrote to end prolonged solitary confinement (greater than 15 days) in American jails, prisons, and detention centers. Please share with others. Click on link below to read and sign the petition.

https://www.change.org/p/helping-professional-organizations-end-prolonged-solitary-confinement

Photo credit: Tim Pearce/Flickr.com

Photo credit: Tim Pearce/Flickr.com

WHAT WOULD YOU DO? by Sherri McGimsey

Tomorrow, I have to go into a team meeting to discuss my son, Matthew, who suffers from schizophrenia. They want me to sign papers giving permission for them to start looking for a new placement for him. For my son and his beautiful mind. He has (for how many days?) been housed in a mental hospital ward, not the ideal place for your son to live but it’s the only place he’s been stable and safe for the past year.

After fourteen years of watching him suffer through depression, delusions, and overwhelming fear, (“Having a rough time“ — that’s what he would call the bad days) how does a parent do this? Sign their sick child away?

If you’ve never seen a young adult decompensate from schizophrenia, it’s like watching your loved one being tortured by his mind. You stand by helpless. Nothing you can do but love him enough to fight him to get the help he needs. I'm not sure if I’m brave enough to let him go after 53 odd hospitals stays, and five times tracking him down when he gets paranoid and does a walk-about. Will all the progress he's made, all the stability he's gained be lost?  

The only place they can find for him to live is far away. Too far for weekly visits, too far for passes on Saturday or Sunday afternoons, too far to cherish the few family moments this illness allows us. Moments others take for granted — to sit and relax, to walk the dogs, to just be with family.

Yesterday was the best he’s been in years. Finding a comfortable, safe, and caring place for him to live shouldn’t be so difficult. But it doesn’t exist — not for our children who suffer from serious mental illness.

So I sit here shaking and wondering if will we survive another calculated risk. Another shift that could send Matthew back into the dark of his illness. He fights the horrible betrayal of his mind, and I fight a system that is broken, and a world that really doesn’t understand the failure to help those who suffer with serious mental illness unless it happens to one of their own. 

I’m going to let this rest for now and enjoy the remainder of my day with our other son and his family. But tell me, what would you do if you had to walk into a meeting tomorrow and sign your sick child away? Would this broken system break your heart too?

 

Postscript:  I want to thank everyone who had us in your prayers and thoughts yesterday. You will never know how much that means when we're navigating the unknown of finding a forever home for our son with SMI. I would also like to say thank you to his team who has cared and worked to get him so stable.

I could not sign our child away.

There is no cure for schizophrenia. Stable is as good as it gets and I want Matthew this stable for as long as humanly possible. Sending you all thank you's, hugs, and love.

Matthew and Sherri

Matthew and Sherri

TOO MUCH PRIVACY by Lynn Nanos LICSW

Although the federal law to protect patients’ confidentiality, Health Insurance Portability and Accountability Act (HIPAA), can appear excessive when it interferes with providing ideal care to psychiatric patients in emergency services, it presents even more challenges in inpatient work. In emergency services, releases of confidentiality documents are unnecessary when involuntary holds are in place. No release of confidentiality document has to be signed by patients to talk with their legal guardians or physician invoked health care proxies. 

I’ve had the privilege of working in both inpatient and emergency psychiatry as a licensed independent clinical social worker. Inpatient cases typically last longer and involve more clinical exploration than emergency services cases. Inpatient units are designed to plan for discharges and aftercare much more than emergency services are. 

It can be nearly impossible to obtain reliable information from a patient who is so disorganized that he or she can barely form a sentence, is highly agitated, is not wanting to be there, and is paranoid. As a social worker on inpatient, I obtained background information from family members or friends of the patients, updated them on progress, and gauged readiness for discharge based on their impression of patients’ progress. Some patients refused to allow me to provide information to anyone on the outside who cared for them.

I knew family members were concerned about patients on my caseload because of the desperation I sensed in their voices and frequency of calls. A young woman in her early twenties was admitted to inpatient because the police found her attempting to stop traffic on the highway. She couldn’t logically explain the reason for doing this after she adamantly denied that she was suicidal. She believed that her admission to the unit was all a misunderstanding and that if only I called the police to clear it up, she could be released. She wasn’t in any ongoing outpatient treatment because she didn’t believe that she was ill. 

Still, on an involuntary hold, the patient refused to sign the documentation that would have rendered her voluntarily there. She also refused to tell us the name and phone number of any family or friend. Apparently no next of kin knew that she was there and there was no family member listed in her chart. Despite her thought process and behaviors being disorganized, the psychiatrist didn’t believe this patient qualified for an extended involuntary commitment and discharged her accordingly.  

Just hours later, this patient’s mother called the unit. The call was transferred to me because I was the social worker and expected to manage most family interactions. After telling me that she’d been calling all local hospitals and police stations, the mother asked me if her daughter was there. During the uncomfortable silence as I struggled to find something to say, she began to cry and said that she'd thought about calling morgues, too. 

I felt horrible. Who was responsible for leaving this mother sick with desperation? Who allowed the psychotic patient to fend for herself without any care? Who dropped the ball? The police officer who authorized the involuntary hold either didn’t care enough to find a next of kin to inform or found it impossible to do so. The hospital emergency department staff couldn’t locate a family member. The patient probably didn’t give them any clue about this. 

Perhaps, if the psychiatrist had asked more questions of the patient and looked more closely at her, she would have understood that she wasn’t ready to be safely discharged. She’d probably have remained on the inpatient unit if her mother had been able to share her concerns early on. But now, there was nothing anyone could do to make things better.  

Aside from speaking in “code” to families, which I've done, there’s not much any of us can do besides advocate and put pressure on the government to make changes. In my forthcoming book, Breakdown: A Clinician’s Experience in a Broken System of Emergency Psychiatry, I offer a simple solution to alleviate HIPAA constraints.

Lynn Nanos

Lynn Nanos

LORD, HAVE MERCY ON US ALL by Anne Schmidt Francisco

I've been scared a lot in life, but only one thing has left such fearful, indelible impressions on my mind. That is experiencing and living inside the third world reality that families like mine endure and fight against. Loving someone who is unaware of his broken brain, who lunges like a speeding train toward the horrors imposed by a society that is neglectful and uncaring. Today, and many days, I feel fearful and afraid. I can't erase the ugly nightmares along the road of losing Josh, nor the suffering of other families. Lord, have mercy on us all.

Anne & Josh

Anne & Josh

Anne writes: This is the last day I saw Josh smile. Delusions of grandeur prevailed in his mind. It was the next day that police took him into custody. He was led like a lamb to the slaughter of incarceration and solitary confinement that ended in his death in prison 19 months later.