Committing Mr. F

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Published  April 2016

In the following story, names and other identifying information have been changed in accordance with confidentiality and medical privacy laws.

 

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“He says he won’t go to the hospital,” I told the paramedics. “But I think he’s a danger to himself.” We looked over at Mr F lying on his living room floor, unable to move. He’d been there for at least three days without food or water and showed signs of increasing agitation.

“I can’t take him unless you have an Order,” one of the paramedics said. “He can refuse treatment if he wants.”

Indeed I had obtained an Order of Protective Custody—Louisiana’s version of a temporary commitment to psychiatric care—and called an ambulance after finding Mr. F, one of my social service clients, in a state of extreme mental and physical distress. Between his fits of anguish, I tried to explain that while I did not know what was going to happen to him at the hospital, I was making a decision on the behalf of his health that I thought was best. I was asking him to trust me in one of the scariest, most doubt-ridden moments of my professional life.

I started working in social services in New Orleans in early 2010, right after I graduated from college with a liberal arts degree in the middle of an economic recession. Determined, like so many in my position, to “make a difference,” I entered the nonprofit sphere. Though I was initially hopeful I’d land somewhere I could be a good, hard-working, helpful person and get paid for it, I ended up jumping from one burnout-inducing job to another.

One such job was to provide glorified babysitting services on overnight and weekend shifts at an inpatient mental health treatment facility. My primary duties included rationing out the morning orange juice and admonishing clients not to have sex with each other in the stairwells. Sometimes I was the only staff member present in a building with upwards of 70 clients. After a few months, I was promoted to working one-on-one with adolescents who had been court-ordered to counseling. At no point was I ever formally trained in therapeutic techniques, crisis management, or diagnostic criteria for mental health conditions. I developed knowledge in these areas by doing the work as best as I could, while consulting with more experienced colleagues and borrowing social work textbooks from friends in graduate school.

As the years went on, I saw the state and local governments divest themselves from indigent healthcare services. I saw a grand-scale push among nonprofit agencies to bankroll databases and managerial consultants instead of resources for clients, cost-of-living raises for staff, or facilities improvements for the buildings in which we operated. I saw whole programs fold under budget cuts. I saw licensed clinical social workers get laid off in favor of less experienced and thereby cheaper workers like me. Everyone, including the clients, seemed expendable in this machinery.

I found I could never trust that I would get managerial support for any decisions I made, as they invariably would run up against some form of litigation concern. “The Department of Health and Hospitals/Medicaid/the Council on Accreditation/etc. is coming this week,” I was frequently warned by supervisors. “Make sure your files are clean.” This directive was a coded reminder that whatever I documented about my clients happened, and whatever I didn’t document didn’t happen. It also meant that any number of outside bureaucratic functionaries could decide to cut me, my job, or my program, in the event that I committed too many paperwork errors. This social service environment had become far more preoccupied with documentation protocols than service quality. In such an anxious milieu, I kept my head down, and learned to trust my own instincts and ethical process.

I gamely trudged along, bringing my own pens to work and hoping that I’d survive the inevitable next round of layoffs. I never asked for a raise. I never left personal items in my desks. I tried to do a good job, but I never felt quite able. Even though for hours every day I performed the emotional labor of talking with people about their feelings and helping them solve their problems, I felt a deep sense of alienation from my work.

blackwoodBefore I made the decision to commit Mr. F, I had spent months with him on developing healthy communication skills, coping mechanisms for his mental health conditions, and medication management techniques. Part of the rhetoric of mental healthcare in Louisiana involves the primacy of “consumer choice.” This is supposed to mean that all services are client-centered, and participation in treatment is voluntary. However, as I experienced working with people literally court-ordered to therapy, in practice the rhetoric of choice is just that. It applies when it is convenient in our underfunded, litigation-obsessed, law-enforcement-colluding healthcare industry.

Mr. F hadn’t engaged with healthcare treatment or medication for months. He had the right to do so; he legally has autonomy over his body. Accordingly, my repeated calls to 911 on his behalf over several days were futile: The paramedics declined to take him to the hospital because he refused to go with them. They wouldn’t even dress his wounds, give him water, or prop him up into a seated position before leaving. Even though he was physically immobile and in the throes of severe emotional distress, he was somehow able to exercise his right to refuse lifesaving medical attention.

However, this right extended only so far, and I happened to know how to limit it. I decided to have him legally forced into psychiatric treatment. My colleagues shot me grim, knowing glances when they heard me announce this. My supervisor told me to trust my judgment, but never explicitly said whether I was making the right or wrong choice. He reminded me to fill out an incident report when it was over.

So it was just me and Mr. F in that moment, at the uneasy crossroads of civil rights and mental illness. Committing him required believing that I knew better than he did about his own health. I arrived at this conclusion after the third or fourth fruitless visit from the paramedics. Finding Mr. F unable even to converse with me, I left him some snacks where he could reach them and went to the coroner’s office.

It is surprisingly easy to commit someone in New Orleans. You don’t even have to be a mental health professional, just a “credible person.” You simply go to the coroner’s office during business hours—because Heaven forbid someone have a breakdown after 4:30 p.m.—explain the situation, and sign a receipt for the Order of Protective Custody. You then go back to the scene of the crisis, call 911, and wait for the police to arrive and take the person away. After a psychiatric evaluation at a hospital, the person is either released or held involuntarily for 72 more hours under a psychiatrist’s order, known as a Physician’s Emergency Certificate. Louisiana is the only state in which the coroner has power to commit people involuntarily.

I wonder how many Mr. Fs there are in New Orleans, who cannot advocate effectively for themselves in medical settings, who don’t understand the limitations of their rights, and who are so gravely vulnerable to the subjective mechanisms of our mental healthcare system.

I had asked the 911 operator to send paramedics and not cops—or better yet, the marvelous but elusive Mobile Crisis Squad, which dispatches social workers—but I guess official emergency protocols dictate the necessity of police in such situations. As such, six officers showed up at Mr. F’s house, none of whom were capable of transporting Mr. F to the hospital and all of whom managed to escalate the situation by agitating the neighbors’ curiosity about the unfolding events. When the paramedics finally arrived, Mr. F again stated he did not want to go to the hospital. They informed him he had no choice.

It was then that my heart broke for him. He clearly did not understand why he had been allowed to refuse medical treatment an hour earlier but not now. He was so scared and angry, and I did not know how to reassure him. After all our months of work together on building self-advocacy and communication skills, I had been the one to force him into doing something he didn’t want to do. I felt I had in some way failed him, even though I had done the only thing I could think of to get him to a healthier place.

Though it is now some time after it happened, I often revisit that episode in my relationship with Mr. F. I wonder if I did the right thing at the right time. I question if I exploited his mental illness to disrobe him of autonomy. I worry that he will never understand that I was trying to help. Mostly I hope he receives the care he needs so he won’t die in the cracks of institutional neglect.

I wonder how many Mr. Fs there are in New Orleans, who cannot advocate effectively for themselves in medical settings, who don’t understand the limitations of their rights, and who are so gravely vulnerable to the subjective mechanisms of our mental healthcare system.

Stories like this rarely meet a public audience, in part out of concern for medical privacy laws, but also because of the deep alienation many of us social service professionals feel in our work. We do not feel empowered to share our experiences because we often do not feel empowered to even have them. We make decisions based largely on the legal or financial consequences of our actions, and on our knowledge of the extremely limited landscape of available resources. Often these decisions do not line up with our instincts, or with the trusting relationships we work so hard to build with clients.

I hope for the sake of Mr. F, others like him, and the well-meaning social workers who try to help them, that someday we are able to build a truly dignified system of care, in which autonomy is valued, ethics are upheld, and health is centered. Maybe if more voices come out of the woodwork we can begin to collaborate on a better way.

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