When a patient threatens terrorism
Mr. Z, an engineering student who works with explosives, says he plans to ‘rid the world of nonbelievers.’ He suffers delusions but repeatedly refuses psychiatric treatment. How would you react?
Parens patriae, or paternalism, refers to government intervention on behalf of persons incapable of managing their lives.1
Psychiatric treatment of unwilling patients is possible in some states. Family members and/or mental health professionals can petition the court to compel outpatient psychiatric treatment.
Because an emergency evaluation produces a thorough and controlled psychiatric assessment (and minimal deprivation of personal liberty), a psychiatrist with any doubt about the patient’s condition should move toward commitment.
Psychiatric patients can be involuntarily committed through a two-step process: emergency hospitalization and judicial commitment.
Laws vary from state to state but they usually allow mental health professionals and law enforcement officials to complete a written statement documenting their belief that an individual suffers from a mental illness and poses substantial danger to self or others.
This form allows police to civilly arrest and transport the individual to a hospital for an emergency evaluation. The hospital then must complete the evaluation within a specified period, usually 24 hours.
If the evaluator finds that the individual is mentally ill and dangerous, he or she must then file an affidavit with the probate court, again within a specified period.
A court hearing is then scheduled. The individual is usually granted due-process rights, including the right to an attorney and an independent psychiatric evaluation. The judge then must decide whether the individual is mentally ill and dangerous, usually based on a “clear and convincing” evidence standard.
Before resorting to legal coercion, try scheduling more-frequent appointments to monitor symptom progression. This would allow faster response when civil commitment criteria are met.
A psychiatrist or other mental health professional can request an emergency evaluation based on information from a knowledgeable intermediary or family member—even if the clinician did not recently or directly interview the patient.2 For example, a psychologist could receive information from a case manager who encountered the patient decompensating. It would be impractical to require a psychiatrist to see a decompensating patient before an evaluation can be ordered.
Hospitalization: A ‘blood-drinking monster’
With no security staff immediately available, the attending psychiatrist and therapist sent Mr. Z home.
The psychiatrist then submitted an application for involuntary hospitalization—in which the doctor summarized the case—and faxed it to the local psychiatric emergency service. The police were notified and—after verifying that the appropriate paperwork had been completed—arrested Mr. Z at his home and brought him to the emergency service for an assessment. Mr. Z was then hospitalized. (Box 1).
Mr. Z was found to be harboring bizarre, grandiose, persecutory, and religious delusions. He claimed that a blood-drinking monster was lurking inside the hospital, and that his hospitalization was part of a conspiracy to persecute Muslims. He considered the Sept. 11 attacks fictitious and claimed that widely broadcast television news footage of the attacks was a computer-animated video. The patient refused all medications while hospitalized.
After 3 days, the court ordered Mr. Z’s discharge, citing lack of evidence that he posed any danger to self or others. At his mental health probate hearing, he managed to conceal his psychotic symptoms while testifying. The court expressed concern over his technical training in explosives but ruled that he was not dangerous because he had never used this knowledge to commit violence.
Upon discharge, Mr. Z declined outpatient psychiatric treatment. The therapist then told Mr. Z that she would terminate psychotherapy after two sessions unless he visited a psychiatrist. Mr. Z again refused, and psychotherapy was terminated.
Although 30 days’ notice is generally appropriate for terminating a provider-patient relationship, a longer or shorter period may be needed depending on:
- Reason for termination. Immediate termination can be justified if the patient has assaulted or threatened the clinician.
- Provider-patient relationship duration. In general, the shorter the relationship, the more leeway there is toward shortening the required notice.
- Type of care being provided. Psychiatric care involving medications or highly intensive interventions calls for longer notice to effect a smooth transition to the next caregiver.
- Availability of alternatives. The general wait time to obtain a new-intake appointment with another psychiatrist needs to be factored into the length of notice.
Letters and notes regarding termination can be used as evidence in court proceedings. When judging a patient abandonment case, the courts will rely on documentation of the reasons for termination and the process used to end treatment.
Source: Slovenko R. Law in psychiatry. New York: Brunner-Routledge, 2002:770-1.
Would you terminate psychotherapy at this point? Could the therapist’s actions be viewed as patient abandonment?
