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Personal Accounts: Invisible on Judgment Day
Jeffrey L. Geller, M.D., M.P.H.
Psychiatric Services 2007; doi: 10.1176/appi.ps.58.2.177
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Dr. Geller, who is editor of this column, is professor of psychiatry in the Department of Psychiatry, University of Massachusetts Medical School, 55 Lake Ave. N., Worcester, MA 01655 (e-mail: jeffrey.geller@umassmed.edu).

I knew I was in trouble when I walked into the small, grungy room and was greeted by the sight of two captious curmudgeons, neither of whom moved when I entered. One was the court magistrate, a sour-faced middle-aged man who looked as if he had drunk too much the night before and was struggling with paying more alimony than he could afford. The other, a police officer I had never seen before, was a middle-aged man who gave the impression of being older than his chronological age and of having gastric ulcers and hemorrhoids competing for his attention.

The room, barely big enough for the two small tables (one gentleman at each) and the four chairs it held, was directly off the noisy courthouse lobby. The magistrate began by grunting something in the direction of the officer, who responded in a voice I imagined might be emitted from a pull-string version of a GI-Joe doll. Because I could barely hear either of them, I asked if I could close the door. I was told "No" by the magistrate, in the same tone of voice as one might say, "Drop dead."

But I get ahead of myself.

On a bright, sunny New England day, I was caught in a speed trap of five police officers, two police cars and two motorcycles, and one radar gun. At the rate of one citation every three minutes (I watched the officers give eight tickets after mine, each delivered with as much expression as one expects from a librarian checking out books), the drivers in this small city some distance from the city where I live were given speeding tickets. This process could best be described as a municipal fundraiser, reminiscent of how the city's off-duty firefighters collect money for charity by extending their boots to drivers stopped at red lights. While one of the officers did the paperwork for my speeding ticket, I asked myself (knowing it was futile to ask him), Why me? What did I really do? Did I deserve this?

My patient (details have been changed to protect the patient's privacy) Charlie, a 6-foot, 2-inch native Hawaiian who had moved to New England because he hated the island's climate and closed-in feeling, was picked up by two city police, both strangers to him. While the psychiatrist signatory and the crisis team evaluator each believed that there were sufficient grounds for involuntary hospital admission, Charlie was bewildered. He asked in different ways, Why me? What did I do? Do I deserve this? But at the time, no one listened, so no one heard and no one answered.

I decided to fight the ticket and appeared before the magistrate—the scene described above. The officer droned off the charge and detection-of-speed process. I then could ask questions. To about 80% of my inquiries, the apparently exasperated policeman said, "I don't know." He never responded to the other 20% because the magistrate said, "You don't have to answer that question" (as if he had answered the others). When I was done, the magistrate asked the officer several questions, some of which were the same ones I had asked. The officer provided substantive answers to each question. I objected to this. Was I really talking a totally different language than these two? The magistrate looked through me as if I were no more than smoke (eye contact was not in his repertoire) and acted as if my ululations had not been heard. These two agents of law enforcement did not seem to have the professional wherewithal to conduct this task. They had too many cases to deal with and really seemed to be doing a rotten rote task that had only one possible outcome. Guilty.

Charlie was processed through the general hospital emergency department, never seeing a psychiatrist (at least not anyone whom the department personnel identified as a psychiatrist), and was sent down the road to the psychiatric hospital for admission—what Charlie calls his "trip to the mental hospital." The psychiatrist at this hospital, who confused Charlie by showing up in scrubs, was doing her fifth admission of the night and had two more waiting. After being assured that he was not talking to a surgeon, Charlie tried to explain himself, but the psychiatrist seemed more interested in filling out the admission forms than in learning about Charlie. She asked questions he had already answered in his free-flowing initial remarks, but apparently he was not where she was on her form. Of course, Charlie didn't have a copy of the form; all he had was his story, his identity, and his life. Charlie felt there was no evaluation and only one outcome. Admit.

I appealed my case to be heard by a real judge. It cost me $20 to do that. This time the police officer who had actually given me the ticket appeared. He testified. I asked him questions. I testified. But the judge, whose name was never mentioned in the courtroom, kept cutting me off. The problem was that anything the officer said was taken as fact. I thought—no, I knew—that he perjured himself. The judge seemed quite understanding and sympathetic, and I thought that he must be a nice guy outside the courtroom. But there was no getting around his basic position of discrediting my information and honoring the police officer's. When he was not treating me as simply invisible, he treated me as confused, misguided, and just plain wrong. Guilty again. But "fine reduced and why don't you appeal?"

Charlie met his public defender 90 seconds before his hearing commenced. He was a harried young lawyer in a threadbare suit that looked as if his father had worn it out. The attending psychiatrist then testified. He was a reticent, bald, bearded, middle-aged man who was difficult to hear and who had met with Charlie twice. His soft-spoken pronouncements were nonetheless delivered with the authority of being beyond a reasonable doubt. Charlie got his chance to tell his story—or at least to start to tell his story. Too many cases and not enough time caused the judge to cut him off. No matter what Charlie said, it felt to him as if no one really listened. The judge prefaced his decision by stating, "Based on all the evidence presented to me …" Later Charlie told me that he thought to himself at that moment, "The judge never 'heard' any of my evidence." Committed. But "you can appeal."

Neither Charlie nor I could really appeal. So why tell us we could? Technically, I guess I could appeal. I'd have to order a transcript and pay many hundreds of dollars for it. I'd need a lawyer. It would be another task that I had no time for. For Charlie, it was possible to file a writ of habeas corpus in superior court. But no one who had been committed to the hospital had ever done so. Neither Charlie nor I had any more places to go to be heard. I had to pay money but could walk out of the courtroom. Charlie had a free pass to more time on a locked ward.

I imply no comparison between Charlie's fate and mine. Certainly the consequences of a speeding violation and of civil commitment are quite distinct. But I do draw a parallel between the two processes and the fundamental defects in both: treating the individual who should be the focus of the proceeding as if he were totally discredited and virtually invisible—someone with no reason and no voice—and conducting the proceedings as if there were only one outcome, with everyone but you in on the joke.

Going through the appeal process sensitized me to the subjective experience of emergency detention and civil commitment. For sure, it's not my first sensitization—or probably my last. But it's an experience that merits repetition.

Perhaps clearer to me than before is a basic tenet: persons going through involuntary procedures in psychiatry must be heard during the process. Is there a worse outcome than for the person who is undergoing a coercive intervention to be treated as if invisible? No doubt in some instances—perhaps many—significant efforts are made to attend to what the patient has to say, but because the patient doesn't like the outcome, the patient feels unheard. Listening pays off in the long run and has few downsides in the short term. If there's not time, then change the time allotment. Don't turn a deaf ear. Hearing is not concurrence. But ignoring what is said may well be the worst form of ignorance there is.

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