Psychiatric Passover || Four Questions

My mother was a very clever lady. She met E. more than once. ‘He’s more than a good friend; he is a good person and a very smart boy.’ E. is a lawyer; Mum would call him the Judge; she took great vicarious pride as E built his sound professional reputation. E was almost like a fourth son.

E and I have maintained our strong friendship till this day. We share a common professional experience, E, and I are both members of the ad-hoc quasi-Judicial Psychiatric Evaluation committees. He is a lawyer and chair, and I am a psychiatrist. The committees evaluate the danger in the mentally ill. We decide if the continuation or inception of compulsory care is justified.

I asked E, Should I publish this?’

First, let me tell you E’s answer-

‘You know that the committees were set up, by law, following the psychiatrists’ request. Before, people lost their liberty in questionable ways. The committees consist of two psychiatrists and one lawyer. The lawyer is the chair.  Another lawyer, funded by the state represents the patient.

We both often respect what the legal rep has to say. Yes, things are wrong. Nevertheless, you must ask yourself,  ‘what do you want?’’’

In Yorkshire fashion, let me tell you what ails me?

Why did I turn to E?

As a Leeds lad, let us call the spade a shovel.

In Israel today, the Psychiatric Hospitals are paralysed by these committees. Most hospitals have two on-going committees per week. The committees invariably take up a full working day and very often continue till the early and late evening. On those days, the junior medical staff cannot function.

The devil is in the details. The legal and medical professions are divided by and in ‘danger.’ In medicine, we define it in terms of probabilities. An overweight, hard-drinking, heavyweight couch potato is liable to have a heart attack. Is it imminent? We do not know. Nevertheless, it should be treated immediately. But when we apply this to mental health, we are entering dangerous ground. The legal profession demands that danger be defined in terms of immediacy. We try to answer.

The legal representatives very often appeal the results.

Direct results of this conundrum are the families who lie or exaggerate the danger; cases are far too often, appealed in a local court. In the appeal, only the patient’s side is represented. The psychiatrists’ reasoning is not explained to the judge. The judgements handed down are amateurish, ill-informed, and often downright counter-intuitive.

Here is an example. The most crucial aim in a first time-hospitalisation is to avoid the second. Avoiding the second hospitalisation is to prevent a lifetime of misery as a chronic patient. But no, the court instructs us, ‘in the first hospitalisation to make the extra effort to find alternatives.’ In other words, discharge early, in accordance to ‘their’ definition of danger. Patients, at a critical juncture, are discharged against the will and advice of the psychiatrists.

In another example, we are told, in the age of Corona to take unnecessary personal risks. As a result of one such decision, a committee was needlessly and avoidably placed in danger.

The courts use a ‘pseudo-psychiatric’ jargon which no one understands. They base their decisions on a complete lack of psychiatric knowledge, often confusing behaviour with illness and muddling cause and effect. The legal profession has little if no understanding of the need to ‘ease the patient,’ back into the community. They do not fully understand either the concept or the logistics. Yet, continuity of care is essential. In today’s psychiatry, it is severely curtailed by inappropriate legal definitions and not psychiatric ones.

The courts, at the behest of the legal representation, harry, bully and oversee psychiatry. The, at best auto-didactic judges have no professional grounding. They place an inordinate and almost mystical belief in medication and little on the ‘magic of the doctor-patient relationship’ — the bedrock of therapy and hope.

Consequently, we are hounded to early-release the patient. The results are disastrous; the patients return to the hospital, and their fate that could have been avoided is set. The medical management of the patient is derailed. Instead of building the essential Doctor-Patient relationship, the patients have a new ally. Someone supports their version, encourages them to fight the therapy that should otherwise start in the hospital. Worse still, the Senior Clinicians abrogate their role in providing over-all care and continuity of services into the community. They let the committee decide. And when it does, the patient is discharged unprepared.

Often, in the committee, the harassed families do not understand why so much effort is expended to release. Families see so little human resources used to treat their loved ones and so much to release them willy-nilly. Often, the families are interrogated as if they were hostile witnesses. Some unkind and abject words have been uttered.

The composition of the committee is highly problematic. We cannot demote a nominated chair (a lawyer) once they are appointed, no matter how unsuited they prove to be. The chairs demand that they all receive equal numbers of sessions. Some sessions are gruelling in particular- some chairs do not cope.

Doctors are replaced, chairs never are. To be a chair is a lifelong sinecure. From day one, they are immune from criticism and fire-proof. This is a significant and inherent problem. The workings of the committee are dictated by two lawyers: an irreplaceable chair and the legal rep. And overseeing the process is a series of judges with little or very doubtful qualification to fill their role. Yet they become ad-hoc, self-appointed experts and omnipotent oracles.

Let me make one point crystal clear. I admire and like the legal reps. They are good people; they have caused me to stop and rethink. In no way are they ambulance chasers. Employed on a renewable contract, they work as part of what has become both a crusade which feels it must ‘save the patients from the psychiatrists.’ An organised, institutionalised public, and well- funded behemoth seated in the Ministry of Justice which is on a perpetual self-righteous rampage. One that, I think, should be questioned. I would wonder why it is so powerful and intimidating? Why were certain reps fired?

I also ask why the reps are allowed into the closed wards ‘looking for clients?’ Is it necessary? Is it the only way? Is it for the good that they see and are seen by people and families who may not want to be seen? How can you protect the rights of an acutely mentally ill patient by signing him or her to a document? This document allows the lawyer to earn money; if the patient signed any other document permitting financial gain, it would not be legally binding. The act, in other circumstances, could be seen in a very negative light.

(I ask similar questions about how the committee members receive recompense.)

I am sure that the committees and the legal representation were set up for good reasons. I am positive that no-one neither envisaged nor welcomes the deleterious spin-offs. When I hear very senior managerial colleagues voice the same sentiments, I know that I am neither wrong nor alone.

So, my dear friend, E, what do I want?

I want ‘SEDER’, which too starts with four questions:

What were we trying to do?
What have we done?
What do we want to do?
How do we want to do it?

As the ‘almost fourth son,’ I am sure that you understand. I wonder if anyone else will.