A Primer on Psychiatric Boarding.

The Wash­ing­ton State Supreme Court recently stated that “psy­chi­atric board­ing” is uncon­sti­tu­tional.1 I agree with and sup­port the court’s deci­sion. “Board­ing” is a ter­ri­ble practice.

To be clear, though, the con­se­quences of this deci­sion may be undesirable.

Some back­ground: In the state of Wash­ing­ton, the only peo­ple who can hos­pi­tal­ize indi­vid­u­als against their will for psy­chi­atric rea­sons are “des­ig­nated men­tal health professionals” (DMHPs). Police offi­cers can bring peo­ple to emer­gency rooms against their wills and physi­cians and other pro­fes­sion­als can eval­u­ate peo­ple who show dis­tress. A DMHP, as an agent of the state, makes the ulti­mate deci­sion whether to detain some­one against his will.

Let’s be clear about this: Being hos­pi­tal­ized against your will is stress­ful, upset­ting, and fright­en­ing. The state is tak­ing away the rights and free­doms from an indi­vid­ual. Civil lib­er­ties? Gone. It is a big deal. No one enjoys the process.

In order for a DMHP to hos­pi­tal­ize some­one against his will, a per­son first must show evi­dence of a “men­tal dis­or­der”.2 Hav­ing a men­tal dis­or­der alone, how­ever, is not rea­son enough to hos­pi­tal­ize some­one against his will. At least one of the fol­low­ing three cri­te­ria must also apply:

  • He is a dan­ger to him­self. (Con­sider a man with major depres­sion who was found nearly uncon­scious; a noose made of bed­sheets was around his neck.)
  • He is a dan­ger to oth­ers. (Con­sider the woman who is walk­ing across the high­way mul­ti­ple times because she believes that God wants her to pros­e­ly­tize to the drivers.)
  • He shows “grave dis­abil­ity”, or is unable to meet his basic needs. (Con­sider the man who has not eaten any food in nearly two weeks because he believes that all food is actu­ally com­posed of his inter­nal organs.)3

Thus, at least two people–the per­son who wanted the indi­vid­ual to go to the hos­pi­tal and the DMHP–were con­cerned enough about the indi­vid­ual to believe that he needed to be in the hos­pi­tal to get care.4

That “to get care” part is the cru­cial point when we talk about “boarding”.

Peo­ple who are invol­un­tar­ily detained in Wash­ing­ton are only allowed to be hos­pi­tal­ized in cer­tain facil­i­ties (or cer­tain beds). Facil­i­ties sub­mit an appli­ca­tion to the state to become a “cer­ti­fied” place where they can treat peo­ple who are hos­pi­tal­ized against their wills.5 These places can be entire build­ings (called “eval­u­a­tion and treat­ment facil­i­ties”, or “E&Ts”, here). They can also be spe­cific beds within a hos­pi­tal, usu­ally on psy­chi­atric wards.

There has been con­cern if “inpa­tient psy­chi­atric capac­ity is suf­fi­cient to meet [a] poten­tial increased demand” for invol­un­tary hos­pi­tal­iza­tions. All cer­ti­fied beds are fre­quently occu­pied. Most peo­ple who are referred for invol­un­tary hos­pi­tal­iza­tion are not in psy­chi­atric hos­pi­tals; they are in hos­pi­tal emer­gency rooms.

There are med­ical cen­ters (and, by exten­sion, hos­pi­tal emer­gency rooms) in Wash­ing­ton State that do not have any psy­chi­atric providers on staff.

Thus, DMHPs have been hos­pi­tal­iz­ing peo­ple against their wills, but no cer­ti­fied treat­ment beds are avail­able. These detained indi­vid­u­als there­fore are admit­ted to hos­pi­tal emer­gency rooms or ran­dom hos­pi­tal wards while they wait for cer­ti­fied beds to open up.

If the hos­pi­tal does not have psy­chi­atric providers on staff, that means these detained indi­vid­u­als don’t receive any psy­chi­atric care. Peo­ple could wait hours, days, or even weeks before they are trans­ferred to a cer­ti­fied facil­ity to receive for­mal psy­chi­atric services.

In the mean­time, these indi­vid­u­als are often phys­i­cally restrained to their beds. There might not be enough hos­pi­tal staff to ful­fill the state’s man­date that they remain in the hos­pi­tal against their wills.

Some­times these indi­vid­u­als receive doses of sedat­ing med­ica­tion for mul­ti­ple days in a row. (Imag­ine you work in an emer­gency depart­ment. Some­one who is detained in your emer­gency depart­ment will not stop scream­ing obscen­i­ties at other patients. He also tries to spit at every­one. He has also tries to punch the nurses when­ever they walk by.)

This isn’t treat­ment. (Remem­ber, the state ordered that this per­son be hos­pi­tal­ized against his will to get care.)

Thus, you can now see why the state supreme court decreed that it is not okay to “board” psy­chi­atric patients. Peo­ple who are detained against their will, by the state’s def­i­n­i­tion, need treat­ment. “Board­ing” isn’t treatment.

This is why I agree with and sup­port the court’s decision.

How­ever, now that you know that there aren’t enough cer­ti­fied psy­chi­atric beds in the state, you can guess what unde­sir­able con­se­quences might come from this decision.

The detained indi­vid­ual in the emer­gency room who yells and tries to punch all the nurses? Now he might end up in jail on charges of assault. Jail is not a ther­a­peu­tic envi­ron­ment. Some jails do not offer any psy­chi­atric ser­vices. Incar­cer­a­tion, like board­ing, is not treatment.

Detained indi­vid­u­als might instead be released into the com­mu­nity if no cer­ti­fied beds are avail­able at that time. Some­one else–another police offi­cer, another fam­ily member–might try to re-refer them back to the hos­pi­tal a few hours after they were released. This results in a cycle in and out of hos­pi­tals and other insti­tu­tions. That isn’t treat­ment, either.

Hos­pi­tals that have cer­ti­fied beds may feel pres­sure to dis­charge peo­ple more quickly due to the height­ened demand. These indi­vid­u­als may not have recov­ered “enough” and may return to the hos­pi­tal much sooner than any­one would like.

Another poten­tial con­se­quence is that those indi­vid­u­als who seek hos­pi­tal ser­vices on their own–perhaps in an effort to avoid invol­un­tary hospitalization–may not be able to get into a hos­pi­tal at all. Those detained against their wills may occupy all of the cer­ti­fied hos­pi­tal beds.

My under­stand­ing is that the state is con­sid­er­ing var­i­ous ways to work with the new law: This includes increas­ing the num­ber of cer­ti­fied beds, cre­at­ing dif­fer­ent options to divert peo­ple from hos­pi­tals, and reduc­ing the amount of refer­rals for invol­un­tary hospitalization.

I don’t under­stand why some hos­pi­tals don’t employ psy­chi­a­trists.6 If a preg­nant woman about to have a baby shows up at an emer­gency room, hos­pi­tals have staff avail­able with the exper­tise to man­age her care.

Why isn’t this the case with psychiatry?

  1. You can read the court’s opin­ion here. It’s a fairly easy read.
  2. A finer point about “show­ing evi­dence of a men­tal dis­or­der” is that there should be some proof that hos­pi­tal­iza­tion is an effec­tive treat­ment for the men­tal dis­or­der in ques­tion. This is why some peo­ple go to jail and not to the hos­pi­tal. This path can lead us into the weeds.
  3. If you think that none of these sce­nar­ios ever really hap­pen, I encour­age you to go vol­un­teer at your local emer­gency room.
  4. For now, let us put aside argu­ments that psy­chi­atric hos­pi­tal­iza­tion is never help­ful or indi­cated. Some peo­ple believe that psy­chi­atric hos­pi­tal­iza­tion is a veiled form of incar­cer­a­tion.
  5. Indeed, there are psy­chi­atric hos­pi­tals in Wash­ing­ton State that are not cer­ti­fied to treat peo­ple who are hos­pi­tal­ized against their wills.
  6. Psy­chi­atric ser­vices are not “rev­enue gen­er­a­tors”, so I sus­pect this is the rea­son why some hos­pi­tals don’t hire psy­chi­a­trists.