Apology and disclaimer

This is in response to questions I get about how to interact (or not interact) with the inpatient mental health system and involuntary commitment. The table of contents is:

1. How can I get outpatient mental health care without much risk of being involuntarily committed to a hospital?

2: How can I get mental health care at a hospital ER without much risk of being involuntarily committed?

3. I would like to get voluntarily committed to a hospital. How can I do that?

4. I am seeking inpatient treatment. How can I make sure that everyone knows I am there voluntarily, and that I don’t get shifted to involuntary status?

5. How can I decide which psychiatric hospital to go to?

6. I am in a psychiatric hospital. How can I make this experience as comfortable as possible?

7. I am in a psychiatric hospital and not happy about it and I want to get out as quickly as possible. What should I do?

8. I am in the psychiatric hospital and I think I am being mistreated. What can I do?

9. I think my friend/family member is in the psychiatric hospital, but nobody will tell me anything.

10. My friend/family member is in the psychiatric hospital and wants to get out as quickly as possible. How can I help them?

11. How will I pay for all of this?

12. I have a friend/family member who really needs psychiatric treatment, but refuses to get it. What can I do?

I am a psychiatrist, which both means I have some useful experience here, and makes it hard for people trying to avoid the system to trust me. Anything written with too much honesty risks degenerating into “here’s how to cheat the system so nobody will know you’re about to commit suicide”. But anything written with too little honesty risks degenerating into some variation of “trust the wise benevolent doctors to do what is best for you”. This is an impossible edge to balance on, and I am sure I fail at one point or another.

But my first excuse is that if somebody doesn’t understand how the commitment system works, they’re not going to innocently blunder into spilling their guts. They’re just going to never go to the psychiatrist at all. If someone wants to avoid ending up in the hospital but doesn’t know how, it’s not like they’re stuck doing everything we want. They can just lie about everything. Or they can just never go to the psychiatrist at all. If they understand a little bit about how the system works, they can at least lie strategically, in the one place where they have to lie, while cooperating 99% of the way.

And my second excuse is that in the end, this is not an adversarial enterprise. Psychiatrists commit people because they’re scared. They’re scared because they can’t predict what the patient is going to do – and on another level, they’re scared because they might get sued if they don’t follow the rules. If patients who aren’t going to hurt themselves know how to explain that they aren’t going to hurt themselves in a way that reassures their psychiatrist, and in a way that doesn’t leave their psychiatrist legally liable for not committing them, then everybody can be more comfortable and get on with the hard work of actual treatment.

This guide applies to adult mental health care only. Child/adolescent mental health care is totally different and I don’t know anything about it. I have only worked in two states, it might be a bit different in other states, and it is definitely a lot different outside the US. Nothing in here is official medical advice. Follow it at your own risk. Please don’t use this to avoid psychiatric care which you actually need. All of this will be wrong in certain situations; when in doubt, trust your intuition.

1: How can I get outpatient mental health care without much risk of being involuntarily committed to a hospital?

Mental health care is divided into inpatient and outpatient settings. Inpatient care means it’s in a hospital, voluntary or otherwise. Outpatient care is your local doctor’s office, or psychiatrist’s office, or therapist’s office.

If you go to a hospital for mental health reasons, your risk of getting involuntarily committed is relatively high – see below for more. If you go to an outpatient provider, your risk is much lower.

In theory, the outpatient system is supposed to provide voluntary treatment, with risk of involuntary commitment only in certain very clearly delineated situations that you can understand and avoid. Each state’s laws are slightly different (and I can’t say anything about non-US countries), but they tend to allow involuntary commitment only in cases of immediate risk of hurting yourself, hurting someone else, or being so psychotic that you could plausibly hurt someone by accident (eg you jump out of a window because you think you can fly).

The key word is “immediate”. If you just have occasional thoughts about suicide, or you have some limited hallucinations but remain grounded in reality, according to the law this is not enough to involuntarily commit you.

In practice, not every mental health professional knows the laws or interprets them the same way, so they can just commit you anyway. The check on this is supposed to be that you can sue them when you get out of the hospital, but almost nobody bothers to do this, and judges and juries usually find in favor of the mental health professional.

So the law isn’t as much protection as it probably should be. In reality your best protection is to only open up to competent people whom you trust, and to frame what’s going on in a way that doesn’t scare them unnecessarily.

Don’t joke about committing suicide. Don’t bring up occasional stray suicidal thoughts if they don’t matter. Don’t say something like “I think about suicide sometimes, but doesn’t everyone?”, because your psychiatrist will have heard the last ten people answer “No, of course I never think about suicide”, and they will not be impressed with your claim about the human condition. Assume that any time you mention suicide, there’s a tiny but real chance of getting committed. If you are actually suicidal, take that chance in order to get help. Otherwise, this is really not the time to bring it up. If you wouldn’t offhandedly chat about terrorism with an airport security guard, don’t offhandedly chat about suicide with a psychiatrist.

(none of this applies to competent psychiatrists whom you trust, but award this status only after many positive experiences over a long-term relationship)

If your psychiatrist asks you outright if you ever have suicidal thoughts, well, tough call. If you don’t, then say you don’t. If you mostly don’t but you are some sort of chronically indecisive person who has trouble giving a straight answer to a question, now is the time to suppress that tendency and just say that you don’t. If you do, but you would never commit suicide and it’s not a big part of why you’re seeing them and you don’t mind lying, you can probably just say you don’t. If you do, and it’s important, and you don’t want to lie about it, then make sure to be very specific about how limited your thoughts are (eg: “I only thought that way once, three years ago) and to add as many of these as are true:

1. “Of course I would never go through with it, but sometimes I think about…”

2. “I love my friend/family member/partner/pet too much to ever go through with it.”

3. “I don’t have any plans for how I would do it.”

4. “I’m [religion], and we believe that God doesn’t want us to commit suicide.”

5. “I’ve been thinking about it for [long time], but the thoughts haven’t gotten any worse lately.”

The same applies to hallucinations and other signs of psychosis. Most people have very minor random hallucinations as they are going to sleep. Most people hear their own thoughts as silent “voices” in their head at least some of the time. Most people who take hallucinogenic drugs will hallucinate. You don’t need to bring these up when someone asks you about hallucinations. If you actually have some troubling psychotic symptoms, then mention them, but add as many of these as are true:

1. “Of course, I know these aren’t really real.”

2. “These have been going on for a while and aren’t any worse lately.”

3. “I would never listen to anything the voices say.”

4. “I only get that way when I’m on drugs / really tired / under a lot of stress.”

If you do all of these things, your chance of getting involuntarily committed to a psychiatric hospital by an outpatient provider is probably one percent or less, unless you’re really really sick.

Notice the words “by an outpatient provider” here. None of this applies if you are in a hospital (eg with pneumonia). If you are in a hospital, be extra careful about this to the point of paranoia. Unless you’re really worried that you might go through with suicide, be careful about mentioning it the hospital. Get your pneumonia or whatever treated, and then go out of the hospital, find a competent outpatient psychiatrist whom you trust, and open up about your issues to them. If you decide to open up to the nurse-assistant giving you a three question psychiatric screen in the pneumonia ward, you may end up on a psychiatric unit regardless of how careful you are, because hospitals don’t take chances.

2: How can I get mental health care at a hospital ER without much risk of being involuntarily committed?

Hospital ERs are not set up to provide psychiatric help to random people. They are set up to evaluate people and decide if it’s a real emergency. If it is, you will be committed to an inpatient unit. If it isn’t, they will tell you to see an outpatient psychiatrist, and you will be back at the beginning except with an extra $5000 bill to pay.

This is not true 100% of the time, and you can take your chances if you want. In particular, if you have extreme anxiety, sometimes they can give you enough fast-acting anti-anxiety medication to calm you down and last you until you can see an outpatient psychiatrist. But going to a hospital ER for any mental-health-related reason other than expecting to get admitted to a hospital psychiatric unit should be a last resort.

3. I would voluntarily like to get committed to a hospital. How can I do that?

If you have a competent outpatient psychiatrist whom you trust, call them up and tell them what’s going on. If they have connections at a local hospital, they may be able to get you directly admitted, which will save you a lot of time and suffering.

Otherwise, you will have to go to a hospital ER. Be prepared for this to be extremely unpleasant. It may take up to 24 hours of sitting in the ER before a psychiatrist can see you. You will probably get examined by nurses, medical students, non-psychiatrist doctors, etc, and each time you will think “Finally! I am getting evaluated and I can get out of this ER!” but you will be wrong. Although there will probably be some crappy food and drink available, there may not be much in the way of entertainment, quiet, or privacy. Do yourself a favor and bring a book or game or something. You may not be allowed to keep your cell phone or laptop or other metal object (more on this later). If family or friends are willing to help, have them come along – if only so they can go out and bring you back real food when you get hungry.

Once you set foot in an ER and mention the word “psychiatry”, you should be prepared for someone to tell you that you’re not allowed to leave until the evaluation is complete. Maybe no one will tell you this, and you can try to leave, and it’ll be fine. But you should be prepared for it not to work.

After many trials and tribulations, you will be examined by a psychiatrist, who will decide whether or not to accept you to the psychiatric unit. You are not guaranteed admission to the unit just because you want it. You might be turned down if the psychiatrist thinks you aren’t sick enough to need it, or if your insurance refuses to pay for it. Insurance companies are very reluctant to pay for hospitalizations unless there is a clear risk involved, so explain what the risk is.

The only thing that (almost) always works is mentioning suicide. If you say you’re suicidal, you will get admitted. If you want to be sure, do the opposite of everything above. Stress that you are suicidal. Stress that it’s not just the occasional fleeting thought, but actually something that you might really go ahead with. If you have a plan, share it.

If you’re not suicidal, expect to have to argue. Talk about what you’ve already tried and why it didn’t work. Talk about all the damage your mental illness has caused in your life. If there’s any chance you might snap and do something horrible – hurt someone, hurt yourself, have some kind of spectacular breakdown – play it up. If you have to, say something vague like “I don’t know what I would do if I couldn’t get help”. Be ready for this not to work, and for the psychiatrist evaluating you to recommend you go to an outpatient psychiatrist.

If you really want help beyond the level of outpatient treatment, but your insurance company won’t budge, ask about a partial hospital program. This is something where you go to a hospital-like environment from 9 to 5 for a few weeks, seeing doctors and getting therapy and classes, but you’re not involuntarily committed and you go home at night. Sometimes insurance companies will be willing to do this as a compromise if you are not suicidal.

4. I am seeking inpatient treatment. How can I make sure that everyone knows I am there voluntarily, and that I don’t get shifted to involuntary status?

I want to be really clear on this: in your head, there might be a huge difference between voluntary and involuntary hospitalization. In your doctor’s head, and in the legal system, these are two very slightly different sets of paperwork with tiny differences between them.

It works like this, with slight variation from state to state: involuntary patients are usually in the hospital for a few days while the doctors evaluate them. If at the end of those few days the doctors decide the patient is safe, they’ll discharge them. If, at the end of those few days, the doctors decide the patient is dangerous, the doctors will file for a hearing before a judge, which will take about a week. The patient will stay in the hospital for that week. 99% of the time the judge will side with the doctors, and the patient will stay until the doctors decide they are safe, usually another week or two.

Voluntary patients are technically allowed to leave whenever, but they have to do this by filing a form saying they want to. Once they file that form, their doctors may keep them in the hospital for a few more days while they decide whether they want to accept the form or challenge it. If they want to challenge it, they will file for a hearing before a judge, which will take about a week. The patient will stay in the hospital for that week. 99% of the time the judge will side with the doctors, and the patient will stay until the doctors decide they are safe, usually another week or two.

You may notice that in both cases, the doctors can keep the patient for a few days, plus however long it takes to have a hearing, plus however long the judge gives them after a hearing. So what’s the difference between voluntary and involuntary hospitalization? Pride, I guess, plus a small percent of cases where the doctors just shrug and say “whatever” when the voluntary patient tries to leave.

Some decent fraction of the time, patients who intended to get voluntarily hospitalized end up involuntarily hospitalized for inscrutable bureaucratic reasons. The one I’m most familiar with is the ambulance ride: suppose the hospital you’re in doesn’t have any psychiatric beds available and wants to send you to the hospital down the road. For inscrutable bureaucratic reasons, they have to send you by ambulance. And for inscrutable bureaucratic reasons, any psychiatric patient transferred by ambulance has to be involuntary. Your doctors don’t care about this, because they know that there is no practical difference between voluntary and involuntary – but if you are still trying to maintain your pride, this might come as kind of a shock.

Some other decent fraction of the time, patients who ought to be involuntarily hospitalized end up voluntarily hospitalized for inscrutable bureaucratic reasons. The one I’m most familiar with is doctors asking patients whom they are committing against their will to sign a voluntary form, ie “Agree to come voluntarily, or else I will commit you involuntarily”. This sounds super Orwellian, but it really is done with the patient’s best interest at heart. Involuntary commitments usually leave some kind of court record, which people can find if they’re searching your name for eg a background check – which could come up anywhere from applying for a job, to trying to buy a gun. Voluntary commitments usually don’t cause this problem. Even though nobody feels very warmly to the psychiatrist telling them to sign voluntarily or else, that psychiatrist is right and you should suck it up and sign the voluntary form.

If given a choice, you should sign voluntary, if only for the background-check reason above. But don’t count on getting the choice, and don’t get too attached to the illusion that it really matters in some deep way.

5. How can I decide which psychiatric hospital to go to?

If it’s an emergency, the answer is “whichever one is closest” or even “whichever one the ambulance you should call right now takes you to.”

If you have a little more leeway, and you have a competent outpatient psychiatrist whom you trust, ask them which one to go to. They will probably be familiar with the local terrain and be able to give you good advice.

If you live in a big city with wealthier and poorer areas, and it’s all the same to your insurance company, try to go to a hospital in the wealthier area. Not only do wealthier people always get nicer things, but – and sorry if this is politically incorrect – you would rather be locked up for a week with the sorts of people who end up in wealthy-area psychiatric hospitals than with the sorts of people who end up in poor-area psychiatric hospitals.

US News & World Report ranks the best psychiatric hospitals. They’re mostly looking at doctor prestige, but I would guess this correlates with other factors patients want in a hospital. If you’re really prestigious you have a lot of money and a lot of eyes watching you, and that probably helps. I suspect teaching hospitals are also good, for the same reason. But these are just guesses.

If you have no other way of figuring this out, you can try looking at Psych Ward Reviews. This site is underused and suffers from the expected bias – you only write about somewhere if you don’t like it – but it’s better than nothing.

Keep in mind that sometimes hospitals will be full, and they will send you to a different hospital instead, and you will not have any say in this.

6. I am in a psychiatric hospital. How can I make this experience as comfortable as possible?

When you go to the hospital ER to get admitted, bring a bag of stuff with you. This should include clothing, fun things to do like books, earplugs, snacks you like, and phone numbers for people you might want to contact.

Keep in mind that you will not be allowed to have anything that could be used as a weapon, for a definition of “could be used as a weapon” which is clearly aimed at MacGyver-level masterminds who can create a railgun out of three paperclips and a stick of gum. The same goes for anything that could be used as a suicide method. This means for example no laced shoes, pillowcases, scarves, and a bunch of other things you will not expect. Basically, bring stuff to the hospital, but expect a decent chance it won’t be allowed in.

Metal objects, including laptops, cell phones, mp3 players, etc, will never be allowed in. These will be taken from you and put in a locker during your stay. If for some reason you have to transfer hospitals during your stay, these things always somehow get lost. Your best bet is to bring a friend with you to the ER, and have them take your cell phone and other valuables.

If you forget to bring a bag of stuff, or if you were committed involuntarily and unexpectedly and didn’t get a chance, call a friend or family member and ask them to bring you your stuff.

7. I am in a psychiatric hospital and not happy about it and I want to get out as quickly as possible. What should I do?

Good news: average stays for psychiatric hospitals have been decreasing for decades, and are now usually a week or less. I did a study on the hospital I worked in and came up with an median stay of 5.9 days, and remember that there are a lot of really sick people bringing up those numbers.

(there are a few states that have laws centered around the number “three days”, but there are also a lot of states that don’t. For some reason the “three days” number has leaked into the general consciousness and everyone expects that to be how long they stay in the hospital. Don’t necessarily expect to get out of the hospital in exactly three days, but do expect it will be closer to 5.9 days than to weeks or months.)

Even better news: contrary to rumor, psychiatrists rarely have a financial incentive to keep people hospitalized. In fact, most hospitals and insurances now encourage quick “turnover” to “open up beds” for the next group of needy patients, and doctors can get bonuses for getting people out as quickly as possible. This should worry everyone else in the hospital who’s getting treated for pneumonia or whatever, but from the perspective of a psychiatric patient who wants to leave quickly it’s pretty good.

If you have a good doctor, you should trust their judgment and do what they say. But if you have a bad doctor, then the only thing you can count on is that they will respond to incentives. Their incentive to get you out quickly is the hospital administrators and insurance companies breathing down their neck. Their incentive to keep you longer is that if you get out of the hospital and ever do anything bad, they can get sued for “missing the signs”. So their goal is to do a token amount of work that proves they evaluated you properly so nothing that happens later is their fault.

That means they’ll keep you for some standard time interval, traditionally (though not always) three days, just so they can say they “monitored” you. If you seem unusually scary in some way, they might monitor you a little longer, up to a week or two. Your chances of successfully convincing them not to do this are essentially nil. Imagine you kill someone a few weeks after leaving the hospital, and during the trial the prosecutor says “The patient was taken to St. Elsewhere Hospital for evaluation of mental status, but discharged early, because he said he didn’t want to have to sit around and be evaluated for the usual amount of time, and his doctor thought this was a reasonable request.” Your doctor is definitely imagining this scenario.

Instead of pleading with your doctors to let you go early, just do everything right. Have meals at mealtime. Go to groups at group time. Groom yourself, not just because you look saner when you’re well-groomed, but because there will actually be nurses monitoring your grooming status and reporting it to the psychiatrists making release decisions. When people tell you things you should do after leaving the hospital, agree that you will definitely do them. If people ask you questions, give reassuring-sounding answers.

For this last one – don’t contradict evidence against you, don’t accuse other people of lying, just downplay whatever you can downplay, admit to what the doctors already believe, and make it sound like things have gotten better. For example, if you were found lying face-down with an empty bottle of pills next to you, don’t say “I didn’t attempt suicide, I just tripped and the pills fell into my mouth!” (I have seriously had patients try this one on me). Don’t say “It was my girlfriend’s fault, she drove me to do it!” Just say something like “That was a really bad night for me, and I don’t remember exactly what happened, but now I’m feeling a lot more hopeful, and I think that was a mistake.”

Don’t overdo it. Nothing is more annoying than the person who’s like “The twenty minutes I’ve been talking with you so far have turned my life around, and now I realize how wrong I was to reject God’s beautiful gift of existence, and am overflowing with abounding joy at the prospect of getting to go back into the world and truly confront my problems with the help of my loving family and…” Just be like “Yeah, things were rough, but I feel a little better now.”

Most important, take the damn drugs.

Yes, I know that some psychiatric drugs are unpleasant or addictive or dangerous or make you feel miserable. I’m not challenging your decision not to want to be on them. But take the damn drugs while you are in the hospital, for 5.9 days. Then, when they let you out, decide if you still want to continue. I guarantee you this will be easier for you, for your psychiatrist, and for the various judges and lawyers involved. The alternative is that you refuse to take the drugs, somebody has to set up a court hearing to get an involuntary treatment order, you have to sit in the hospital for weeks while the legal system gets its act together, the psychiatrists finally get the order and drug you against your will, and then after however many weeks or months, you get released from the hospital and stop taking the drugs.

If you have a good doctor whom you trust, then talk to them about the drugs and make a decision together. Let them know if there are any side effects. If a drug isn’t working for you, tell them, so they can switch it. Be honest, and willing to stand up for yourself, but also open-minded and ready to listen.

But if you have a bad doctor, just take the damn drugs. Bring up side effects, mention anything that’s intolerable, but when – like bad doctors everywhere – they ignore you, just take the damn drugs. Then, when you get out of the hospital, go to a competent outpatient psychiatrist whom you trust, tell them the drugs aren’t right for you, and talk it over with them until you come up with a better plan.

This is a good general principle for everything: agree to whatever people ask you while you’re in the hospital, talk to a competent outpatient psychiatrist whom you trust once you get out, and decide which things to stick to. I remember working with a doctor who wanted to discharge his patient to some kind of outpatient drug rehab. The patient refused to go, so the doctor wouldn’t discharge her, and they were in a stalemate over it for weeks, and the whole time the patient was tearfully begging the doctor to release her. I cannot tell you how much willpower it took not to sneak into the patient’s room and yell at her “JUST AGREE TO GO TO THE REHAB AND THEN DON’T DO IT, YOU IDIOT”. I mean, I am as in favor of Truth as everyone else, but I don’t even think her doctor cared if she went to the rehab or not. He just wanted to be able to document “Patient agreed to go to rehab”, so that when she started taking drugs again, he would have ironclad court-admissable evidence that it wasn’t his fault.

Finally, your doctors will be very interested in “discharge planning”, ie making sure you have somewhere safe to be after you leave the hospital. They may not be willing to believe you about this. So get a family member (best) or friend (second-best) on your side. Have them agree to tell the doctors that they will watch over you after you leave, make sure you take your medication, make sure you get to your follow-up outpatient psychiatrist appointments, make sure you don’t take any illegal drugs. Your best bet for this is your mother – psychiatrists love mothers. Tell your doctors “I talked to my mother, she’s really concerned about my condition, she says that I can stay with her after I leave and she’s going to watch me really closely and make sure I’m okay”. Only say this if it’s true, because your doctors will call your mother and make sure of it. But if you can make this work, this is really helpful.

Even if all of this works, it’s just going to get you out of the hospital in a bit less than 5.9 days instead of a bit more than 5.9 days. There’s no good way to get out instantly. Sorry.

8. I am in the psychiatric hospital and I think I am being mistreated. What can I do?

Your best bet is to find someone with a position like “Recipient Rights Representative” or “Patient Rights Advocate”. Most states mandate that all psychiatric hospitals have a person like this. Their job is to listen to people’s concerns and investigate. Usually the doctors hate them, which I take as a pretty good sign that they are actually independent and do their job. If you haven’t already gotten a pamphlet about this person when you were admitted, ask the front desk or your nurse or someone else who seems to know what’s going on how to contact this person.

You may be able to switch doctors or nurses. Just go to the front desk or someone else official-looking and ask. I don’t think this is a legally codified right, but sometimes nobody cares enough to refuse. Keep in mind that if you switch doctors, you may have to stay longer so that the new doctor can do their three-day-or-so assessment of you, separate from the last doctor’s three-day-or-so assessment.

Threats don’t work. Everybody makes threats, and everyone at the hospital is used to them. Threatening to hire a lawyer is especially boring and overdone and will not even get anyone’s attention.

Actually hiring a lawyer will definitely get people’s attention, but it’s a high-variance strategy. Remember that it’s very hard to get a doctor not to hold you for a three-day-or-so evaluation, and that most people are released before anything goes to court anyway (a court hearing can take weeks to set up). I have mostly seen this work in cases where I have no idea what the doctors are thinking and everybody seems sort of confused and just letting the patient sit in the hospital for no reason. Lawyers can be a very good incentive for people to un-confuse themselves. I am not a lawyer, I have tried to avoid the state of prolonged confusion where lawyers become necessary, and I don’t want to give any legal advice beyond saying it will definitely get people’s attention. But I would feel bad if someone read this, hired a lawyer, found them not to be genuinely helpful (as in fact they probably will not be), and then got a huge legal bill.

Some people wait until they get out, then comparison-shop from the outside world and hire a lawyer to sue the people who mistreated them in the past. If you’re going to do this, document everything. Your doctors are documenting everything, and if one side comes in with perfect documentation and the other side just has vague memories, the first side will win. By “document everything”, I mean have a piece of paper where you write down things like “2:41 PM on October 10: Nurse Roberts threw a pencil at me. Informed such-and-such a person and they refused to help. Informed such-and-such another person and they also refused to help.” Write down exactly where and when everything took place – the psychiatric hospital may have video surveillance, and if everybody knows which videos to get, it will make life much easier. Report everything to the Patient Rights Advocate, even if they’re useless, just so you can call them up and have them testify you reported it to them at the time. I am not a lawyer, this is not legal advice, and your lawyer will be able to tell you much more – but documentation never hurts.

If things are really bad, figure out if there are surveillance cameras, and hang out in front of them.

Once you leave the hospital, consider giving feedback. Most hospitals will have some kind of survey or hotline or something that lets you praise hospital staff whom you liked and report hospital staff whom you didn’t like. This won’t heal any wounds you suffered – and while in the hospital, threatening to report a doctor will be ignored just like all threats – but it might help somebody way down the line. You can also write a report on Psych Ward Reviews. In fact, do this anyway, whether you’re mistreated or not, so that other people can learn which hospitals don’t mistreat people.

9. I think my friend/family member is in the psychiatric hospital, but nobody will tell me anything.

Yes, this definitely sounds like the sort of thing that happens.

Because of medical privacy laws, it is illegal to tell a person’s friend or family that they are in the psychiatric hospital, or which psychiatric hospital they’re in, without their consent. If the person is too paranoid, angry, or confused to give consent, then their friends and family won’t have a good way to figure out what’s going on.

Your best bet is to call every psychiatric hospital that they could plausibly be in and ask “Is [PERSON’S NAME] there?” Sometimes, all except one of them will say “No”, and one of them will say “Due to medical privacy laws, we can’t tell you”. I know this sounds ridiculous, but it really works.

Once you have some idea which hospital your friend is in, call and ask to speak to them. They will say something like “Due to medical privacy laws, we can’t tell you if that person is here.” Say “I understand that, but could you please just ask them if they’re willing to speak to me right now?” If they are willing to speak to you, problem solved. Otherwise, you might still get some information based on whether the person leaves you on hold for a while in a way that suggests she’s going to your friend and asking them whether they want to talk to you.

You can also ask to speak to (or leave a message for) the doctor taking care of your friend. The receptionist will say “Due to medical privacy laws, we can’t tell you if that person is here.” Say “I understand that, but I have some important information about their case that I want the doctor to know. They don’t need to tell me whether my friend is there or not, just listen.” At this point, all but the most committed receptionists will either admit that your friend isn’t there, or actually get a doctor or take a message. There is no doctor in the world who is so committed to medical privacy that they will waste time listening to the history of a patient they don’t really have just to maintain a charade, so if you actually get a doctor this is a really strong sign.

Once you have a good idea where your friend is, you can ask the receptionist to pass a message along to them, like “Call me at [this phone number]”. If they still don’t respond – well, that’s their right.

Most hospitals will have visiting hours. Going to visit someone who refuses to let you know they’re at the hospital and refuses to give anyone consent to talk to you is a high-variance strategy, but you can always try.

10. My friend/family member is in the psychiatric hospital and wants to get out as quickly as possible. How can I help them?

First, make sure they actually want to get out as quickly as possible, and you’re not just assuming this. You would be surprised how many people miss this step.

Second, make sure they know everything in section 7 here.

Third, offer to talk to the doctors. Doctors often don’t trust mentally ill patients, but they usually trust family members. If your friend isn’t sick enough to need to be in the hospital, tell the doctors that. Describe the circumstances around their admission and why it’s not as bad as it looks. Mention how well you know the person, and how you’ve been with them through their illness, and how you know they would never do anything dangerous. Only say this if it’s true – if they’re in the hospital for stabbing a police officer, your “they would never do anything truly dangerous” claim is just going to make you look like an idiot.

Offer to help with discharge planning (see the end of section 6). Tell them that the patient will be staying with you after they leave the hospital, that you’re going to be watching them closely to make sure that they’re safe, that you’ll make sure they take their medications and go to followup appointments. Again, only say this if it’s true – or at the very least, coordinate with the patient, so you don’t say “My son will be staying with me under my close supervision.” and then your son ruins it all by saying “Haha, as if.”

If you have a sob story, tell it. If you are ninety-seven years old and your son is the only person who is able to take care of you and bring you to your doctors’ appointments, mention that. Sob stories from patients generally don’t work, but sob stories from family members might.

Offer to come to the hospital during visiting hours and meet with the doctors. This both underlines everything above – it shows you’re really invested in their care – and also gives you a good opportunity to pressure the doctors face to face. I don’t mean you should threaten them or be a jerk about it, but just ask “Why can’t Johnny come home? We really need Johnny at home to help with the chores. Everyone at home misses Johnny.” I don’t guarantee this will work, but it will work a little, on certain people.

If there are many people in your family who are willing to work on this, use whoever is closest to the patient (eg their mother) – and in case of a tie use the person who is the most upstanding high-status member of society. A promise to take care of someone sounds better coming from a family member who is a doctor themselves (or a lawyer, or a teacher) compared to from the patient’s unemployed stoner brother with a NO FEAR tattoo.

As somebody who is not in a psychiatric hospital, you are in a much better position to hire a lawyer if one needs to be hired. Again, in the majority of cases a patient won’t even stay long enough to have a court hearing. If you are poor and have limited resources, this is definitely not how I would recommend using them. But if you have money to burn, or your friend/family member is being held for an inexplicable amount of time (longer than a week or two) and you don’t know why, you are going to be in a much better position to take care of this than the patient themselves.

Even if all this works, it’s just going to make someone stay a bit less than 5.9 days instead of a bit more than 5.9 days. There’s no good way to get someone out instantly.

11. How will I pay for all of this?

If you don’t have health insurance, there is usually some kind of state/county mental health insurance program that is supposed to help with this kind of thing. You usually have to earn below a certain amount to qualify. Your social worker at the hospital can talk to you about this. I am not promising you such a program will exist – if you’re concerned about money, look into this before you go to the hospital.

If you do have health insurance, they may pay for your admission. The problem is that they have to decide if you are really ill enough to need psychiatric care, and they make this determination separately from the doctors who decide whether to commit you or not. In the worst case scenario, you can be involuntarily committed because your doctors decided you needed care, but your health insurance refuses to pay for it because they decided you didn’t need care. If this happens, you are stuck with the bill. This is horrifying and there should be some kind of law against it, but I’ve seen it happen and I think it’s legal.

Your best bet in these cases is to try to get the state/county mental health insurance mentioned above. Sometimes you can sign up for it after you leave the hospital, and then get your costs reimbursed.

If everything goes wrong, and you’re stuck with a bill and no insurance company willing to pay it, try to argue the hospital down. Hospitals know that the average random sick person can’t afford to pay $20,000 or whatever ridiculous amount they charge. They make these numbers up as part of a complicated plot to fool insurance companies into overpaying, which never works, and they expect patients to try to bargain. They are also usually willing to consider whatever payment plan you think you can make work. I don’t know very much about this, but there’s some more information here.

As far as I know, committing people involuntarily and leaving them with a huge bill is legal, and hiring a lawyer will not help with this. I don’t know much, so you may want to ask a lawyer’s opinion anyway, if you can afford it.

12. I have a friend/family member who really needs psychiatric treatment, but refuses to get it. What can I do?

If your family member is not a danger to themselves or others, your options are limited. You can try to convince them to voluntarily seek treatment, but if it doesn’t work, it doesn’t work.

If your family member is a danger to themselves or others, you have a good case for getting them involuntarily committed to the hospital. A good example of this would be them threatening to hurt you, or actually hurting you, or being so out of touch with reality that you are legitimately afraid they might hurt you or themselves. Them being paranoid (“people are out to get me”) or extremely confused about basic reality (“I am able to fly”) counts as legitimate reason to believe they might hurt you or themselves. If this describes your family member, document everything worrying that they say or do so you can present it to the doctors doing the assessment and (eventually) the courts.

Then, if your family member is cooperative/confused enough to let you drive them to the hospital, drive them to a hospital ER. If they’re not this cooperative, call the police and they will take things from there. Be prepared for the police to potentially put your family member in handcuffs and be really aggressive and police-y about it (and if you have a dog, arrange for it to be somewhere else at the time – like stuck in a bedroom with the door closed). The police will bring your family member to the hospital ER. You should go to the hospital ER too, so that you can tell the doctors what’s wrong and why you think they need treatment – ie why they are dangerous or potentially dangerous.

The most common way this ends is that your family member goes to the hospital, is started on some drugs, gets a little better, goes home, stops taking the drugs, and gets worse again. If the doctors at the hospital are not competent, they may not think about this. It may end up being your job to insist on some kind of longer-term solution.

If your family member is psychotic, then the gold standard for longer-term solutions is a long-acting injectable antipsychotic medication. This is a shot that a nurse can give them which will give them a few months’ worth of antipsychotics all at once, safely. This way they don’t have to remember/agree to take their medication at home. Then a few months later you can wrangle them back to a doctor’s office where someone can give them the shot again; repeat as needed. If your family member doesn’t agree to this, you’re going to need a judge’s order – but judges are really cooperative with this kind of thing and your psychiatrist can tell you more about how to make this happen. A partial hospital program can also help with this.

There is a kind of institution with different names everywhere, usually something like “Assertive Community Treatment”, which basically consists of some mental health professionals in a van who go around to people’s houses and make sure they’re okay / staying on medication after they’ve been discharged from the hospital. These are chronically underfunded and you have to fight to get into them, but if nothing else works you can see if there’s one of them in your area. These people are also good at wrangling patients to get their monthly dose of long-acting injectable antipsychotics.

If you need a quick way to deal with a family member’s psychosis, and they refuse to take antipsychotic medicine, and they don’t meet criteria for involuntary hospital admission – well, I can’t believe I’m saying this, and this is super not medical advice – but cannabidiol, a chemical in marijuana, is a weak but functional antipsychotic. Normal marijuana is awful for this situation and contains lots of other chemicals that make psychosis worse, but you can get special cannabidiol-only strains that act sort of like weak non-prescription antipsychotic medication. In a state like California where marijuana is legal, you can talk to a marijuana expert about which strains these are and how to use them. In a state where only medical marijuana is legal, you can take your family member to a random quack to get them a medical marijuana card, then follow the same process. Most psychotic people refuse to believe that they are psychotic, but most of them are very anxious. If you frame the marijuana as a way to help with their anxiety, they may go along with it. Then they might get non-psychotic enough to make them understand there’s a problem, after which they can go to a psychiatrist and get a longer-term solution. Again, this is definitely not medical advice and if you have any other options you should take those instead.

You can get a lot more (and much more responsible) advice from the Treatment Advocacy Center, a non-profit that helps people figure out how to get their friends and family members psychiatric treatment.

Postscript

All of this is to prepare you for worst-case scenarios. Many people seek inpatient mental health treatment, find it very helpful, and consider it a positive experience. According to a survey on Shrink Rap (heavily selected population, possibly brigaded, not to be taken too seriously) about 40% of people who were involuntarily committed to psychiatric hospitals eventually decided it was helpful for them. This fits my experience as well. Be careful, but don’t avoid getting treatment if you really need it.