10 Actual, Concrete Recommendations for Unfucking the Incentives that Shape the Psychiatric Crisis System

(that don’t involve spending more money)

This post emerged, as writing often does, out of frustration at people ‘being wrong on the internet’ (in a manner of speaking). I’ve lost count now of how many people I’ve spoken to who, when asked how we should improve the mental health crisis system, answer either 1) increase funding for their pet treatment (which they, coincidentally, get paid for, as a provider of said favourite treatment), 2) abolish the system (without any follow-up steps as to how the abolishing might be accomplished) or 3) with a reformulation of their favourite complaint about the system, and no practical strategies at all.

So, if a magic genie (or Scott Wiener) gave me a magic wand with, say, the ability to wish 10 changes into being immediately, here they are. It should be obvious that even if Senator Wiener did grant me my wishes, there would still be more problems than you could shake a stick at remaining. Baby steps. (This may become a series, TBD).

1. Change the question that must be answered in a court hearing to decide on involuntary commitment from ‘is it likely the person will harm themselves or others outside of a locked psych ward?’ to ‘Is a locked ward stay likely to help the person feel well enough not to hurt themselves?’.

Why:

Currently, involuntary commitment hearings only need to determine that a person will harm themselves if they don’t go to hospital, not that they’re less likely to harm themselves if they do go to hospital. This means involuntary commitment decisions completely ignore ‘backlash effects’, where someone comes out of hospital feeling more suicidal than when they went in. 

How:

Get an amendment passed to change the criteria in the involuntary commitment laws of an influential US state. This might be helped by taking an individual’s court case to the Supreme Court to get involuntary commitment where there is evidence of previous iatrogenic harm determined to be a bad idea. Probably this would need to be done with the collaboration of some mental health court judges, and it would be helpful to educate more mental health judges about iatrogenic harms so they are supportive of the change.

2. Change the hospital design policies for a state or hospital system to ban bright, cool lighting in psych wards, and specify warm, soft lighting, with the option for circadian lighting.

Why: 

Blue lights are fucking depressing. Replacing lightbulbs when they need to be replaced is cheap and easy, already gonna happen anyway, and unlikely to be contested because nobody really cares. If a hospital admin is really invested they could install circadian lights, which will probably help people whose psych issues are related to sleeping, but some hospital admins won’t give a fuck about that so mandating it is unlikely to work. 

How: 

Figure out which policies specify which lightbulbs get installed in psych wards (it’s probably a hospital-level policy, but there’s some chance it’s a government policy). Figure out which hospital execs are responsible for setting that policy. Network at hospital conferences until you meet them, then sell them on the plan.

3. Ban the diagnosis of personality disorders by emergency department physicians.

Why: 

By their own definition, psychiatrists consider personality disorders to be problems you can only identify in the long-term, stable characteristics of a person. An ED psychiatrist generally sees a person for a 15-min conversation while they’re in huge distress, which is too short and not representative of their ordinary lives. Personality disorder diagnoses weigh heavily on patients and may make them more anxious about their mental state (particularly without counselling around what it means and how someone gets better).

How: 

I’m actually not sure who has the authority to ban this. Maybe the WHO committee who decides on the ICD-10? Maybe the DSM committee at the APA? Maybe the association of emergency physicians. Figure out who has this authority, then convince them and their constituents to change it.

4. Revoke counties’ right to use involuntary commitment laws to force people into locked facilities if the available capacity of its voluntary alternatives falls below the capacity needed to offer a voluntary alternative in 95% of crisis calls.

Why:

Locked facilities use the sort of force we normally reserve for taking accused criminals to jail, except for people in a huge amount of distress. In an ideal world, there would be plenty of places people could go (or be taken to) if they needed psych treatment (that is, a therapeutic environment, offering medications, with expertise from clinicians) without needing to also give up their bodily autonomy. However, most counties don’t build any voluntary facilities and only build involuntary ones, because it’s easier and they have to have the locked ones by law. Requiring counties to earn their use of force by ensuring voluntary alternatives will minimise the number of real involuntary holds required (because people will have more appealing options). Plus, if counties lose their right to enforce holds for a period of time and nothing terrible happens, it may build support for reformulating involuntary commitment laws altogether. 

How:

Probably, decades of advocacy and political capital-building in a promising state that already has -some- voluntary facilities open, to get state legislative amendments passed to amend the involuntary commitment legislation to put the rule in place.

5. Convince some well-respected famous clinical psychologists to get very good at crisis de-escalation.

Why: 

Currently therapy training involves no first-hand practice at crisis de-escalation. It seems to be unfashionable–crisis jobs are often lower paid, with higher turnover and lower autonomy. Making it sexy requires well-respected members of the field doing it, so that newer trainees see their role models doing it, and eventually demand crisis de-escalation training in their coursework.

How:

Network with the relevant famous psychologists, offer them training, and ask them to  document their experience publicly (e.g. on social media).

6. Ban charging patients or insurers for involuntary hospital stays.

Why:

If you think about it for five seconds, charging someone for a service they by definition didn’t want seems like it should be extremely illegal, and yet it’s not. Plus, if hospitals can’t reliably get paid for involuntary stays they’ll get more nervous about approving them because it will hurt their profitability. It wouldn’t change Medicaid-funded stays, but it would be a start.

How:

Probably advocate to pass some state legislation again. California could probably do it. 

7. Make 72-hour involuntary holds inclusive of holidays and weekends, not exclusive.

Why:

Being locked up against your will is awful anyways. But being locked up two extra days for no reason other than it’s the weekend is stupid and dehumanising, plus it puts people who are on involuntary holds at more risk of losing their job because of absences. There would be a bit of extra work for weekend on-call psychiatrists in doing evaluations, and maybe they would have to do more handover work with their weekday colleagues, but worth it if lots of people get let out earlier (good for the hospital’s capacity planning and throughput too).

How:

State legislation again wheeee (I think). 

8. Make publishing the proportion of crisis calls that ended in involuntary commitment a condition of Medicaid or county grant funding for mental health crisis teams.

Why:

Once involuntary commitment numbers are public, teams will be motivated to reduce them, and making funding conditional on an action is the fastest way to make a government-funded program do anything.

How: 

Figure out who the relevant public administrators are and convince them to adopt this policy. It’s probably at least a state behavioral health department, if not the Federal Medicaid Centre.

9. Start a new scientific journal just for papers published by practicing crisis clinicians.

Why:

Number of papers published in prestigious journals is the ultimate yardstick in science, but it has basically zero correlation with how much the research is used by practitioners. Most research on crisis care is published by non-practitioners, and even the research that is published by practitioners is rarely published by crisis practitioners. This means the whole research enterprise is not particularly integrated into actual practice. Making ‘publishing from the field’ sexy could bring more ‘I’m not sure if I’ll go into research or clinical practice’ people into crisis work. 

How:

However one goes about starting a scientific journal? Or, take the journal that’s already published by the American Association of Suicidology and make it open to publishing by practicing clinicians only. 

10. Eliminate ‘gotta already have possession of the property before we’ll approve your funding’ requirements for state behavioral health infrastructure funding.

Why:

This may be a California-specific problem, but–I’ve spoken to the leaders of several nonprofits that run alternatives to psych hospitalisation (peer respites, short-term stay places) who are blocked from opening new centers because:

• In order to apply for the state infrastructure funding to purchase the property for the program, they have to have the property locked in, 

• but they have to apply for the funding many months before it might be approved, 

• so they can’t use that funding to pay for the property they want to buy or rent in the meantime. 

Landlords and sellers generally can’t afford to wait for months to see whether the deal will go through, so the nonprofit loses the property because of the delay in finding out about the outcome of the grant funding. 

How:

Be the state behavioural health department head. Change the policy in the grant documentation (perhaps only for smaller projects).

If you have the authority to move the needle on any of these system changes, let’s talk. (Or, if you know how to make any of them happen!) Jess@psychcrisis.org.