
Feds probing psychiatric hospitals for locking in patients to boost profits - Deinos
https://arstechnica.com/science/2017/05/top-us-psychiatric-hospital-chain-investigated-for-keeping-patients-too-long/
======
phren0logy
I'm a psychiatrist, and there are a few things to consider about this story:

1\. The bulk of people in a psychiatric hospital are there voluntarily. They
can walk out the door at any time.

2\. When a patient is in a hospital involuntarily, their stay is subject to
state laws about involuntary hospitalization. This, as far as I know,
universally requires 2 independent professional opinions that a patient is
actively suicidal, actively homicidal, or overtly incapable of taking care of
themselves to the point it puts their health at risk.

3\. Psychiatric stays are generally very short (less than 5 days), despite the
fact that most medications don't start working that quickly. Stays have become
unrealistically short.

4\. Despite the general outcry about involuntary hospitalization, most family
members of a person with a severe illness will tell you that they struggle to
get their loved ones admitted even when the situation gets dire.

5\. Again despite the outcry, a number of states have been expanding the
liability of psychiatrists for the actions of their patients. For example, if
my patient were to hurt themselves or someone else, I can expect years of
depositions and lawsuits. This does not justify hospitalizing someone who does
not need it, but does speak to a double standard about our role in protecting
society.

THIS LIABILITY STILL APPLIES WHEN AN INSURANCE COMPANY TELLS ME THEY ARE GOING
TO STOP PAYING FOR HOSPITAL TIME 2 DAYS AFTER SOMEONE TRIED TO HANG
THEMSELVES. If I release them, it's on me. If I keep them, they face huge
bills even if they have insurance. This sucks.

6\. MOST IMPORTANTLY, __WITHOUT INVOLUNTARY COMMITMENT MANY PATIENTS GO TO
JAIL OR PRISON __. I work in correctional settings. The decline in psychiatric
beds is strongly correlated with the spike in mentally ill people behind bars.
Without an avenue to get them treated, they end up getting arrested for their
behavior, when they should have gotten treatment instead.

~~~
brookside
Firstly, it must be incredibly difficult to work with severely mentally ill
populations, so I commend and thank you for taking on that responsibility.

It troubles me, however, to to give a government the capability to detain
citizens based on the (forgive the scare quotes) "medical" expertise of a
psychiatrist. This has been abused [1] and I find significant issues with the
credence given to testimony by psychiatrists in the US court system [2]. The
lack of science in ever-shifting diagnosis criteria is saddening, and these
diagnoses will mirror the prevailing social and political winds. Within some
of our lifetimes, of course, homosexuality was a pathology in the DSM.

I'm not sure of the answer here. We do need a way to keep people who are a
threat to themselves and others in a safe place, but psychiatry has been and
is such a troubling and far-too non-scientific endeavor, long drawing profit
from conclusions far beyond our true capabilities to understand the human mind
and behavior. I don't want people in the field with anything other than an
attitude utter humility and possibly shame exerting control over others'
lives.

[1]
[https://en.wikipedia.org/wiki/Political_abuse_of_psychiatry_...](https://en.wikipedia.org/wiki/Political_abuse_of_psychiatry_in_the_Soviet_Union)

[2] [http://www.newyorker.com/magazine/2009/09/07/trial-by-
fire](http://www.newyorker.com/magazine/2009/09/07/trial-by-fire)

~~~
yourapostasy
> I'm not sure the answer here.

Has anyone started making lots (like tens of thousands) high-resolution, 3D,
video ( _i.e.,_ not still snapshots, but over time and ideally during episodic
moments) MRI and CAT scans of diagnosed psychiatric patients, pointed a deep
learning system at the scans, and see if patterns can be detected? If the deep
learning systems can pick up patterns we didn't notice before, then that could
be a valuable empirical tool to add.

~~~
phren0logy
Yes, but this is expensive and difficult, and not many people volunteer to
participate.

~~~
yourapostasy
"Yes this should be tried", or "Yes, someone has started doing this"? If the
latter, can you please post a link to their effort?

~~~
phren0logy
[http://journals.plos.org/plosone/article?id=10.1371/journal....](http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0119089)

------
entropy128
This is an appropriate article to comment with the Rosenhan Experiment. From
Wikipedia: _The study involved the use of healthy associates or
"pseudopatients" who briefly feigned auditory hallucinations in an attempt to
gain admission to 12 different psychiatric hospitals in five different states
in various locations in the United States. All were admitted and diagnosed
with psychiatric disorders.

After admission, the pseudopatients acted normally and told staff that they
felt fine and had no longer experienced any additional hallucinations. All
were forced to admit to having a mental illness and agree to take
antipsychotic drugs as a condition of their release. The average time that the
patients spent in the hospital was 19 days. All but one were diagnosed with
schizophrenia "in remission" before their release._ [1]

This article also makes me think Wells Fargo-esque pressure from above is to
blame, but won't be heavily punished by the authorities. At least in the WF
case two executives had to pay back $75m. [2]

[1]
[https://en.wikipedia.org/wiki/Rosenhan_experiment](https://en.wikipedia.org/wiki/Rosenhan_experiment)

[2]
[https://www.washingtonpost.com/news/business/wp/2017/04/10/w...](https://www.washingtonpost.com/news/business/wp/2017/04/10/wells-
fargo-knew-about-sham-accounts-problem-as-far-back-as-2002)

~~~
phkahler
That's an interesting experiment, but what was the expected outcome? The
deliberately feigned illness to get in and then reverted to completely normal.
That's not a class of patient that is ever expected to show up. How would
someone expect those cases to be handled and why?

~~~
Doxin
You'd at the very least expect medical experts to be able to identify non-ill
people. That part of the experiment isn't the most damning though, The part
where they told hospitals they'd repeat the experiment and then _didn 't_ is.
Suddenly the hospitals managed to finger many of their patients as
pseudopatients when in fact they weren't even part of the experiment.

So yeah, a mental health industry that can't differentiate between sane and
insane in either direction scares me.

------
eth0up
I once met a mural artist who told me a very memorable story of his peculiar
time at the cuckoo's nest, how he got there and how he left. It was the
1960s-70s and all had been reasonably normal in his life, until his attendance
at a certain party. Though he was untroubled in the company of recreational
drug fiends, he didn't participate, at least not deliberately. However,
someone had surreptitiously spiked the punchbowl with LSD. Being a gentle and
kind sort of creature, he unwittingly embarked on a profound psychedelic
odyssey. Still under the effects of the punch and yet unable to rationalize
the situation, he called his sister for help, who persuaded him against his
better judgment to check in to a psychiatric hospital. Shortly after, his
state of mind returned to normal where he was able to assess the cause, but
the talons of the ward took hold and would not let him go. They'd already
begun to medicate him heavily with tranquilizers which clouded his mind and
dulled his resolve. His pleas for understanding were ignored and he soon
realized that he'd become a prisoner. In this situation his only assets were
his art and good character. In a sanctioned stupor he devised a plan; he would
begin "cheeking" his medicine in the presence of the nurses and spitting it
out in their absence. He was permitted art supplies, the results of which
quickly earned him respect among the staff. He'd use this to eventually obtain
permission to paint outside in the courtyard, where he'd scan every possible
vector for a way out. His fear had began to impel him after seeing inmates
which were previously articulate and sociable become zombies after what he
presumed were lobotomies. He suspected he was on the list for the same. Once
he gained the trust of the staff, he finally sprang for freedom. He got it and
never returned. He carried on with his art, remaining perfectly sane,
innocuous and successful in his trade.

------
mabbo
A great example of how for-profit healthcare (or anything else) can fail.

Corporate entities have an obligation to do whatever they can legally get away
with in order to maximize profits. They do not have a prerogative to benefit
society, or help human beings apart from what they choose to do.

Every country has to decide whether the benefits of privatisation of the
various services outweighs the societal costs caused by private entities
having different goals.

~~~
wu-ikkyu
Public psychiatric institutions suffer from the same problem though, because
the salaries of the employees running the institution are dependent upon a
consistent occupancy.

~~~
lumberjack
Not really. Public sector employees aren't as incentivised to maximise profits
for their employer as private sector employees are. This ultimately makes some
public services superior because the employees have no reason to pretend you
are are walking wallet instead of a human being.

~~~
mason240
The history of public institutions has shown otherwise.

------
jstanley
This is one of my greatest fears: that I'll be labelled as insane, then taken
away and locked up against my will, and when I try to plead sanity, nobody
will believe me. Because they "know" I'm insane.

~~~
DanBC
Make an advanced directive, and speak to your nearest relative.

I'm not sure of the law in the US, but I think you have to pose an active
danger to yourself or other people for them to detain you, and they can only
hold you for short times.

Abuses do happen (which is why you need to talk to your nearest relative and
get and advance directive in place) but they're rare.

[https://en.wikipedia.org/wiki/Involuntary_commitment_interna...](https://en.wikipedia.org/wiki/Involuntary_commitment_internationally#United_States)

~~~
psyc
Unfortunately, justice is glacial, and the law doesn't protect you in the
short term. The devil is in the implementation, and the actors.

You don't have to be a danger to yourself or others. Only one psychiatrist in
the ER has to _say_ that they estimate you are. I'm not aware they have any
incentive _not_ to hold you, and increase their liability.

Next, you'll hear they can hold you for 72 hours to evaluate you. That's
meaningless. They can hold you for as long as they want to. At the end of 72
hours they can decide to commit you, or even easier, they can bully you into
admitting yourself voluntarily, implying they'll commit you otherwise. If you
stay "voluntarily" and then try to sign out at a later date, they can again
bully you by threatening to take you to court.

If they commit you, you get a court hearing a few weeks later. The rules of
the hearing couldn't be simpler: the judge does exactly what the psychiatrist
recommends, full stop. After that, appeals become increasingly fewer and
further between.

If you're being held 'wrongly' (i.e. you disagree with their assessment)
you're entirely on your own to find competent advocates. It can be very
difficult, and it can take months before you find someone who wants to make
anything happen. Last time I was in, it took me 2 months of working the phone
every day, until I somehow managed to reach a high-up lawyer with the state
board of oversight. And they just happened to be a nice person who sympathized
with my situation.

As I said upthread, you really do not want to get committed if you have state
insurance. Private insurance will try to shorten your stay. State insurance
leaves you at the hands of the institution. Until I found that lawyer (who had
me out after another 2 weeks) the doctors were working on transferring me to a
long-term state hospital.

~~~
tcj_phx
Everything you say here is basically what I've observed.

> Unfortunately, justice is glacial, and the law doesn't protect you in the
> short term.

I got a court order freeing my girlfriend from the first hospital in a day and
a half. Then I made the minor mistake of returning to the hospital without a
police escort, and they succeeded at sucking her into the system. It's been
slow-motion anti-justice ever since.

> Last time I was in, it took me 2 months of working the phone every day,
> until I somehow managed to reach a high-up lawyer with the state board of
> oversight. And they just happened to be a nice person who sympathized with
> my situation.

Thanks for sharing this. My current case is in the court of appeals, and is
probably going to take another 3+ months. This is something I can do to
hopefully get the treatment providers to stop their palliative treatments more
promptly.

------
seibelj
My grandma was kept alive an extra 10 days to let her medicare run out in
rural Oklahoma. I'm not sure of all the details because it was 15 years ago
and I was a teenager, but my dad said medicare stopped paying for some level
of care and then they let her die (she was a vegetable from a stroke).

------
wu-ikkyu
Private prisons profit from recidivism (rather than rehabilitation) just as
psychiatric "hospitals" do.

Though at least in a private prison, you _know_ how long your sentence is, it
is an objective measure.

When imprisoned in a mental asylum, _you don 't know how long you will be in
there for_, because your release is dependent on the subjective whim of those
who stand to profit from the continued occupancy.

There are no objective tests to determine whether or not a person is mentally
ill, and this further exacerbates the existing conflict of interest.

~~~
microcolonel
This is why there needs to be third-party monitoring, with enormous penalties
for misconduct. Public or private, there is no way to make sure this isn't
happening unless a hostile party is watching everything.

------
Overtonwindow
You mean like private prisons that trump up charges to extend inmate sentences
for profit???

------
DarkKomunalec
Looking forward to charges of fraud and, where applicable, imprisonment under
false pretenses[1], resulting in stiff prison sentences for those responsible.

[1]: The notion that psychiatric hospitals should be able to keep people there
against their will is _extremely_ suspect. A possible exception is a patient
being convicted in court of an actual crime, and sent there instead of to
prison by the legal system. Even then, the very likely possibility that the
hospital staff would extend the patients stay indefinitely would necessitate
the judge setting some upper bound on how long the patient can be kept against
their will.

~~~
Jare
> The notion that psychiatric hospitals should be able to keep people there
> against their will is extremely suspect

It is necessary to some extent because of the impact that mental and
psychiatric conditions have on the will itself. But some patient-appointed
external agent with formal qualifications and the power to balance decisions,
even if imperfect, would go a long ways.

~~~
DarkKomunalec
Necessary or not, no institution should have the power to imprison without all
the safeguards of a criminal trial.

~~~
outlace
Every state does it differently but in California, you can be held
involuntarily for up to 3 days just on the judgement of police or a
psychiatrist but being held longer than that does require a hearing with a
judge and an attorney where the patient, however impaired or not, can plead
their case.

