To the Editor
Re: “Depressed? New York Screens People at Risk” (News, Weds., April 1, 2005)
In my experience psychiatric screening should not be undertaken with haste, NJ's Psychiatric Emergency Screening laws serve as an example of how democratized screening removed from psychiatrists and psychologists in the name of greater access to health care can turn into an autocratic, profit-at-the-expense of service system. Originally set up in 1989, the emergency screening program is our statewide system for controlling access to psychiatric hospitals and the heart of the system is the screener and the screening process which overrides the opinion of a patient's therapist or psychiatrist as to whether a person is actually in need of hospitalization. Each state county contracts with private companies to provide the services stipulated by the state law. These companies' staff a 24-hour phone support line generally linked to a “screening center” in the psychiatric ER of a regional hospital and offered to residents as a community service. In Bergen County, where I have experienced the tyranny of the system, CarePlus/NJ located in Bergen Regional Medical Center in Paramus operate screening. CarePlus/NJ is part of a large national corporation and although they receive public funds, they charge a sizable fee for access psychiatric hospitalization through screening at one of their centers or by “mobile outreach screeners” dispatched by law enforcement, or primarily by “certified screeners” who staff the phone support lines.
The individuals at the phone bank are not upfront with callers about their status as “certified screeners” and what the legal ramifications might be of any given call. Thus, “certified screeners” have power to force hospitalization or set in motion involuntary commitment, yet most of what is known outside mental health circles is the numbers are frequently recommended to county residents as empathic listeners or a source of referrals to other county services in the interest of promoting access and awareness about mental health programs in the region. Unfortunately, as I found out during a benign call I placed last December, hoping to resolve some conflicting emotions about an issue, the empathic listener can conversationally drag the caller into a highly subjective “risk assessment.” While holding minimal clinical credentials (in some cases I've talked to screeners with only a BA in psychology and the agency's training), they are empowered to make decisions, which deprive citizens who have not transgressed the law of the full protection of the Bill of Rights. Without informing the caller they are being screened and without administering recognized and standardized psychiatric scales, inventories or questionnaires, the “certified screeners” are permitted to make idiosyncratic risk evaluations based on their impressions and undisclosed criteria that a caller poses a danger and is in need of further involuntary evaluation.
In my case, I had no warning that I was being assessed for anything, nor told what I'd said that made the woman “concerned” enough to “suggest” she send an ambulance, so I reassured her that I was not anywhere near that upset. According to her mysterious set of diagnostic tools, that reassurance cost me a chance at voluntarily going to a hospital where I was in an outpatient program at one of the hospital's clinics (and because I was not made aware of her “assessment” I was denied best practice standards of being treated where my records were held.) Unbeknownst to me, the screener was so certain I fit her profile for “imminent danger” she violated my privacy and had the County police trace my cell phone and the municipal police could now enter my house without a warrant and hold me there until the “mobile screener” arrived. Of course this is all in retrospect, at the time as far as I knew the phone call ended with a three-part exchange: the screener asked if I could contract for my safety; my affirmation of that contract; and lastly her final reminder that they were there if needed.
The “mobile screener” is a similarly low-end mental health professional who makes a multiaxial diagnosis (a clinical diagnosis without administering anything resembling a full DSM-IV interview). Assesses for current suicidal ideation or threats without using diagnostic tools like the gold standard in suicide screening the Suicidal Ideation Scale or evaluating current behavior (i.e. writing a suicide note, asking if they had reasons to live, how much control do they feel over any suicidal thoughts). Most importantly, lacking the clinical social worker title, he or she is permitted to determine whether the person fits the “dangerous to self or others” criteria for involuntary commitment relying only on his or her own judgment and then arranges transport to a psychiatric ER. Once in the psychiatric ER, the “mobile screener” disappears to write-up his or her impressions from the interview. The ER psychiatrist, in my case a resident, asked me two questions: “what were my previous diagnoses” and “did I want to harm myself?” when I denied having intentions to harm myself I was informed the Dr. had to speak with CarePlus before she determined if and when I might leave.
Detained in the ER indefinitely and without any information about the interchange between the screener and the psychiatrist, I later discovered the screeners report given to the interviewing psychiatrist contained numerous inaccuracies about my medical history and contained sizable errors in vital information. Later, while going over my records, I was surprised to see the psychiatrist had not even bothered to fill out most of the forms completely. Neither the screener, nor the psychiatrist bothered to check with my therapist of three years, or any of the many professionals I'd worked with in the intensive outpatient program I had just completed to verify the information or acquire more complete information about me. Even with the failure to follow up with my private treatment team, and the botched reporting I was involuntarily committed, yet never told that I was, nor why, nor for how long. Neither the psychiatrist nor the screener explained why private therapists, psychiatrist, just completing an Intensive Group therapy program, were unsatisfactory treatment options. NJ law states involuntary commitment is a “last resort” and judiciously invoked (ironically when permitted to leave, I was discharged to those same professionals and that group program and why that wasn't a valid option at midnight on December 27 but was at 11 am on December 30 has never been explained). “McScreeners” whose only evidence I was dangerous were the glaring errors written into a report, caused my illegal detention, denial of due process, and loss of a host of other Constitutional rights. Since they staff for-profit mental health agencies at cut-rate prices, NJ residents are no longer administered the proper evaluations to determine risk and diagnose mental illness. Best practice procedures would eat up time and cost money to hire properly credentialed medical psychiatrists. Ironically, involuntary commitments produce one of the highest rates of recidivism (near 35%) -improper treatment conveniently boosts profits!
Before the 72 hours CarePlus/NJ's employees have to build a judicial case for commitment, the hospital discharged me. Discharging me seemed clear evidence the commitment was unwarranted and I was infuriated at the ease and unconcern with which my rights as a citizen were revoked. Thus, I set out to file a grievance. I was shuffled from agency to agency only to find in NJ's mental health system there is no way to make a formal grievance, all one can do is complain to the agencies and departments originally responsible for the errors. I supplied incontrovertible proof of the errors: compiled medial records, insurance statements, pay stubs; each one showing the information used to commit me was wrong and they all went ignored by the bureaucrats. CarePlus went so far as to personally insult me by stating I didn't know what I was talking about because I couldn't sort out fact from fiction because of my “crisis.” Therefore, all was “procedure.” It is a shame that a law designed to make treatment more accessible is run by giant corporations empowered to hire minimally qualified mental health workers.Through “quickie” screenings that discount the patient's words and actions and valorize the screener's impressions, the process is even more dehumanizing. The only possible reason I believe I was committed is these degraded screenings operate on profiles. The screener went down the list of characteristics considered “high risk” and decided sharing enough past history with percentages was the same as exhibiting current suicidal gestures or behaviors that most competent professionals assess. Irresponsible quick screens look for stereotypes and resort to profiling instead of a clinical diagnosis and staff believe that if it is procedure, it is legal.
Mini-screenings by pseudo-professionals not qualified to understand the complexities of the human psyche are not a way to bring treatment to those who might not otherwise make use of it. I shudder at the thought of a specially devised 9-item depression screening given to someone suspected of depression. While depression may be treatable, it virtually requires one understand (according to the DSM-IV) “the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.” Rather than being diagnosed (however provisionally) by a quiz, forced into treatment, or mired in a state system that arbitrarily assigns levels of care based on the first impressions of less than diligent employees protected by “self-regulating” agencies with profit-making agendas, one must generally be motivated to seek out a mental health ally in order to progress toward recovery. Without providing motivation, safety, and reassurance, screening fails the therapeutic mantra: “do no harm.”
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