From the Corvallis Advocate, JANUARY 9, 2021 by Andy Thompson
Editor’s Note: The names and other identifying information of the family in this story have been changed
For family and other onlookers, a psychotic break can look like someone that’s suddenly devolved into delusional thoughts or paranoia, and even hallucinations. Angela Jaffrey puts it this way: “When someone has a psychotic break, you know it, even if they don’t.”
Jaffrey recounts her ex-husband calling to let her know their son Eric had been admitted to the emergency department at Corvallis’ Good Samaritan Regional Medical Center.
“I understood immediately what had happened when Mike called me,” Angela says. They had both seen Eric become progressively more agitated the week or two prior – he couldn’t focus on even the simplest task, and had all but stopped sleeping. The final decision to bring Eric to the hospital came when he talked about people being out to get him, and saying that he would be better off dead.
Angela describes herself as being of two minds that morning – on the one hand, terrified and helpless to do anything for her son, and on the other hand, determined to remain cool headed and do whatever was required to assure the best outcome possible for Eric, no matter what. That determination would prove defining later on.
Angela says, “You can’t entirely blame the hospital or Benton County’s mental health system, but they should be coordinating, and they’re not, and if that hasn’t already been tragic, it will be sometime.”
Broken Procedures
Angela rushed to the hospital, and after several hours of waiting, she got to speak with a nurse who explained Eric was having some sort of psychotic episode, and that they had given him Ativan which had calmed him down. The nurse also explained the drug was a temporary fix, because they didn’t know what was causing the episode.
Indeed, according to the National Alliance on Mental Illness, psychosis is a symptom, not an illness – it can be caused by a range of things, either physical or mental. Whatever the cause, the brain is basically experiencing a stress overload. Although, there is good reason to treat the symptom in this instance, a psychotic break can lead to harming oneself or others, and there is some evidence that an untreated episode can lead to neural degeneration.
Angela revealed to the nurse that members from both sides of Eric’s family had bipolar disorder. She asked the nurse what was next, if Eric would be admitted to Samaritan’s psychiatric unit. The nurse told her a county social worker would be visiting Eric, and then making that decision.
Angela says the social worker didn’t come for several hours, and when she finally visited Eric, she concluded he was calm and lucid – that he could be released the next morning.
Angela was mystified. Did the social worker not understand how Eric was behaving before the Ativan was administered? Did she not understand the emergency room had to deploy three security staff just to keep Eric from hurting himself or others? Was she unaware that Eric’s family had members with a bipolar disorder?
According to Angela, the social worker admitted it was probably the Ativan that calmed him, and that he was probably going to need some kind of further treatment, but she had no idea what he would need. Angela questioned if releasing Eric seemed like the best course, and the social worker only repeated again that there was nothing she could do.
The Hunt for Help
“When I called the hospital the next morning, they said Eric had already been released, so I called Mike, who told me he’d picked him up, but had to get to work, so he dropped Eric downtown,” Angela says.
Eric had been talking about suicide and also about defending himself against people who were out to get him just 24 hours earlier. At this point, she describes herself as both angry with the hospital and Mike, and scared for Eric. So, she felt fortunate when Eric answered her call, and then met her.
She recounts spending the day trying to find help.
The social worker suggested Eric could be seen as a drop-in at the health department, so she tried that, but describes the trip as unhelpful: “Eric was met by both a substance abuse counselor, and an LCSW [Licensed Clinical Social Worker], neither seemed to connect with Eric, and after 15 minutes, he just walked out.”
Next, Angela took Eric to see his primary care physician, who prescribed a sedative. According to Angela, the primary care doctor said it was the most he was comfortable prescribing, and that what Eric really needed was to see a psychiatrist – which Angela had already anticipated. What she hoped for was a referral from the doctor, and he did offer her referrals, but he also cautioned that getting him an appointment would be difficult because there aren’t enough psychiatrists in the area.
The next few days were a blur of Angela calling every psychiatrist in town to find waiting lists of six months or more – and Eric becoming progressively more paranoid, agitated, and even threatening.
Notably, Angela had Eric on her health insurance, a policy that offers fairly generous psychiatric benefits. So with nobody local able to see Eric, Angela called her insurer’s hotline, and the hunt for a psychiatrist turned somewhat statewide, with a psychiatrist identified in Portland that Eric could see.
It Gets Worse
However, not even a day passed and Mike brought Eric back to the emergency room. Worse yet, he had persuaded Eric to exclude Angela from the list of people who could see him. Mike was also trying to persuade hospital staff and the county social worker to withhold information from her, which to their credit they were unwilling to do.
“Mike was doing what he used to do when our kids were younger, when we were getting divorced,” Angela says. “He’d swoop into whatever was going on, whether it was tutoring, wisdom teeth being removed, or anything else, and he’d work to derail whatever was being put into place for Eric – for no reason that anyone could figure out.” She also says their divorce was high conflict, with him taking her to court almost constantly, which she characterized as making single parenting not only hard, but almost impossible.
“Luckily, while the social worker wasn’t willing to hold Eric long enough to get a real diagnosis, she was willing to hold him longer than last time,” Angela says. After talking with the social worker, she had become persuaded that the best thing for Eric would be admission to Samaritan’s Psychiatric ward.
However, her ex-husband, Eric’s father, quickly dashed any thoughts she had that they could present their son a united front and persuade him to voluntarily accept treatment at Samaritan’s Psychiatric ward. In fact, she says, he was totally against it, and at this point, she still had no direct access to her son.
Angela feared Eric was deteriorating fast, and that his only chance at recovery laid in getting sustained attention from the right professional – in this instance, a psychiatrist. She feared the county social worker didn’t have the authority or resources to really help Eric, and she could see a future of temporary fixes at the emergency room leading to a path that could only spiral downward.
She left the hospital that night resolved that she would contact an attorney first thing in the morning – that she would seek guardianship of her 21-year–old son.
Enter a Good Lawyer
The next morning, Angela was referred to several attorney’s offices, and eventually found one willing to move quickly. She let the county’s social worker know what was happening, which she believes helped the social worker decide to continue Eric’s hold another day. The court granted Angela temporary guardianship the next day, and awarded her a longer term guardianship later.
She had Eric moved to Samaritan’s Psychiatric ward, and in a little less than a week they had settled on a cocktail of mood stabilizers and antipsychotic medications. On discharge, they arranged for Eric to start seeing both a Corvallis psychiatrist and a counselor.
And Today
It is three years later, and Angela says Eric is doing just fine. “He’s working, and is busy just being a normal 24-year-old.”
She does say that the first few months were dicey. Eric continued to need medications for some time, but both he and the psychiatrist agreed that he may not have a bipolar disorder, and that he could try going without meds. Once off the meds, it became apparent something else had caused the psychotic break.
“Eric’s recollection of events leading to the psychotic break are still fuzzy. He said some things that could have indicated a trauma, others depression, and others indicating he’d abused some sort of drug – we may never know why he had a psychotic break,” Angela says, adding that he doesn’t take his own wellbeing for granted, like some people his age might, and that the experience may have made him more conscientious of his mental health.
The Takeaways
Angela says, “In fairness, placing someone in treatment against their will probably should involve checks and balances, but the county social worker should have some authority to do that, and should know someone dosed with Ativan is going to act differently than when they were brought to the emergency room.”
She points out that, when Eric was at the ER the second time, and the social worker knew it was the second visit in about a week, that things did change.
Eric’s mother had experience enough to know her son’s situation needed intervention, and the resources to make it happen. But, Angela says, she worries that not everyone would question the decisions of a county official, or have the resources to get help like she did.
Angela says, “What I saw wasn’t going to go away on its own, and to just keep bringing Eric to the emergency room may have kept him temporarily safe a couple times, but eventually, that was going to fail.”
What Angela questions is why good psychiatric care should necessarily have to rely navigating the legal system – and what happens to someone who doesn’t have a family advocating for them.
Navigating a Psychotic Episode in Benton County
From the Corvallis Advocate, January 9, 2021 – by Cody Mann
Suffering a psychotic break is a nightmare scenario for many people. Watching a loved one suffer may possibly be worse. Or worse yet would be watching a loved one falling into the hole of psychosis and being unable to get the help they need because of a bureaucracy that you never expected or a system that is, for all intents and purposes, broken.
A psychosis might be the symptom of a problem, but if the person experiencing it is too medicated to explain how they came to the point of breaking, then how can the system work for them. Too often, in the process of seeking psychiatric evaluations or treatments, some people fall through the cracks of the mental health system.
Who Gets Committed?
If someone in the emergency department at Good Samaritan Regional Medical Center appears to have significant mental health concerns such as paranoid delusions or talk of violence towards self or others, Benton County Health Department may get called in to provide a risk assessment, evaluation and recommendation regarding admission to a psychiatric unit – either voluntarily or as a custodial hold. Hospital staff make the final decision.
A psychotic episode may create challenges in determining the validity of a person’s reporting, but may not change the recommendation if it’s determined that the episode doesn’t present an imminent risk to the person or others, and is able to meet their basic needs in the immediate future, according to Dannielle Brown, behavioral health director, Benton County Health Department.
Brown said the county health department becomes responsible if a person is placed on a hospital hold, which initiates a pre-commitment investigation by the county. The process transitions from a treatment focus to a legal focus, determining if the person is at continuing risk and needs to be committed for up to 180 days. The recommendation is taken to the court, and a judge makes a ruling on commitment based on the pre-commitment report.
“The individual remains a patient of the hospital who is providing treatment, whether that is Good Samaritan or another inpatient hospital location,” Brown said in an email. “If the person is assessed to need a referral to the Oregon State Hospital by the hospital treatment team, the county is required to support this decision and assist with the referral but the hospital is responsible for the actual referral process to Oregon Health Authority.”
Noting that long-term psychiatric care, as was historically provided, is no longer an option in Oregon, Brown said placement in the Oregon State Hospital or any inpatient psychiatric hospital is short-term, with the intention of stabilizing the patient and moving them to the lowest level of care for ongoing support. That might include adult foster care or residential treatment, but neither of those are considered by the state to be long-term treatment options, according to Brown.
Looking at the numbers, the Benton County crisis team is busy, evaluating upwards of 15 people on any given day and also providing in-the-moment crisis counseling services. Most of the people the team sees don’t meet the criteria for inpatient admission, much less involuntary admission, Brown said.
“We average approximately 6-10 pre-commitment investigations in any given month, with an average of about 10% of these actually being high enough risk to require a civil commitment court hearing,” Brown said in the email.
And frequent visits to the emergency department won’t necessarily result in admission to a psychiatric ward either. The evaluation and assessment process remain the same each time – a determination is made as to whether the person is an imminent risk to self or others. Brown compared it to a person making repeated visits for a stomach ache that led to no findings requiring medical treatment, meaning the person would be sent home.
“There would need to be some medical condition that would require inpatient admission for treatment of a medical condition. This is the same for mental health conditions,” she said. “The determination is made around medical necessity/appropriateness for inpatient care.”
Limiting Funding, Resources
Oregon Revised Statutes (chapter 426) and Oregon Administrative Rules (309-019 and 309-033) contain rules that community mental health programs must follow for many of the services being provided. That includes crisis services and pre-commitment investigations. But Brown says the issue is less about laws and rules, and more about the limited funding and resources available for mental health services. She adds that behavioral health treatment services have been underfunded historically, in part due to a longstanding expectation that such treatment should be community based.
“There are not enough resources to support the number of individuals experiencing mental health conditions effectively. When looking at the money that is spent in medical care and treatment, mental health services make up an average of 3-5% of these dollars,” Brown said. “The medical system is receiving 95-97% of the dollars that are identified for treatment. The issue is not around the rules that must be followed, rather it is the limited availability of resources to support service provision.”
Brown said the mental health system has grown adept at managing dollars efficiently and doing as much as it can with as little resources as possible. She said when you add in the lack of parity for insurance companies to fund mental health treatment the same as they do medical services, the mental health system becomes hamstrung.
“We will continue to do the best we can with the limited resources we have available but the real need is to better fund the mental health treatment programs,” she said.
If someone is in crisis, and seemingly suddenly experiencing paranoid delusions, expressing thoughts of violence towards themselves or others, and also experiencing hallucinations, Benton County has crisis therapists available around the clock. Any community member can access the counselor of the day services during business hours by walking into the Health Services Building at 530 NW 27th Ave.
After-hours services are primarily provided at Good Samaritan Regional Medical Center’s emergency department. County crisis therapists will do crisis/risk assessments and provide in-the-moment crisis counseling services.
Good Samaritan Regional Medical Center did not respond to questions for this report.
What about Guardianship?
So, what if the person needs help, but doesn’t want it? What options does their family have? People have the right to refuse medical treatment even if it could kill them. However, if a person is found legally incapacitated – their decision-making is impaired to the extent they cannot safely care for themselves – someone else can petition the court for guardianship.
Attorney Rance Shaw with The Reynolds Law Firm said in an email that, when people are unable to make healthcare decisions for themselves, a healthcare representative will be needed to make medical decisions for them. The document appointing a healthcare representative must be signed and notarized while the person for whom it applies is still considered “capable.” When the person who has a healthcare representative is deemed “incapable,” then the representative may begin making decisions.
“The statute authorizing the appointment of a healthcare representative states, ‘Incapable means that in the opinion of the court . . . or in the opinion of the principal’s attending physician . . . a principal lacks the ability to make and communicate health care decisions to health care providers,’” Shaw said in the email. “In my experience, however, doctors are rightfully wary of ignoring the wishes of an individual who has not been found incapable by a court.”
Shaw said a guardianship is an extreme remedy, with the petitioner asking the court to strip autonomy from the allegedly incapacitated person. He said those seeking a guardianship must determine whether they’re dealing with stubbornness or if the person is actually unable to understand what’s happening. An informed decision made by a capable person, even if against medical advice, does not support a finding that a guardianship is appropriate.
“A guardianship is likely the best option when the proposed protected person has declining capacity (e.g., progressive dementia),” Shaw said. “Speaking purely anecdotally, individuals with declining capacity typically do not realize the point at which decision making authority should be handed to someone else. A guardianship is also likely the best option when the individual has or has attempted to inflict self-harm.”
Potential guardians should also weigh their ability to serve in the role and recognize the adversarial nature of guardianship proceedings, which could strain relations with a person in need of care. Shaw cited statistics that show the majority of proposed guardians are family members of the protected person and said because of the intense commitment required of the guardian, as well as the potential effect on family relationships, a guardianship should only be sought if it appears there are no other reasonable options for ensuring the safety of the individual in crisis.
Guardianships involving psychiatric patients in crisis are tricky, Shaw said. As noted above, whether temporary or indefinite, it’s an extreme remedy because it deprives a person of their autonomy. This is especially true when the petitioner seeks a guardianship without prior notice to the proposed protected person.
Shaw hopes the law will evolve to soften the adversarial nature of guardianship proceedings. He’s seen court-required mediation suggested as a reform method, and he thinks that when dealing with a psychiatric patient in crisis, the petitioner must be able to quickly obtain a temporary guardianship without prior notice to ensure the person does not commit self-harm.
He said mediation shortly after the appointment of the temporary guardian would provide the parties with the opportunity to explain their sides and get feedback from a neutral third party before (and hopefully instead of) heading to a contested case hearing to argue the necessity of a guardianship. Unlike a contested hearing, mediation would not be on the record, and the mediator facilitates the discussion without taking sides.
“I am not sure how feasible or successful this approach would be, but I believe there needs to be a path to a temporary guardianship over a psychiatric patient in crisis with a less deleterious effect on the relationship between the protected person and the petitioner/guardian,” Shaw said.
What’s the Process?
There are two avenues for pursuing a guardianship based on whether the situation is an emergency or not. If it’s not an emergency, someone files a petition for the appointment of a guardian, which contains information on the petitioner, proposed guardian (if not the petitioner), proposed protected person, physicians/counselors, contact information for people with knowledge of the incapacity, and a factual basis supporting the need for a guardianship.
The petition is then served on the protected person, along with a form allowing the person to object to the guardianship. The guardianship statutes include a list of everyone entitled to notice of proceedings, and written notices must be sent as well. At least 15 days must be given to object, and objections may be filed by the proposed protected person or anyone else who was notified.
During that time, the court sends someone to interview the proposed protected person, the proposed guardian, doctors, and others with relevant information, and then files a report with the court stating whether it is believed the guardianship is appropriate.
“Things get complicated when an objection is filed, so I’ll just say that a contested guardianship is time consuming, even more emotionally draining for the parties, and much more expensive,” Shaw said. “A non-emergency guardianship may continue for as long as the individual remains incapacitated, though the letters of guardianship (the court-stamped document giving the guardian its authority) expire each year. The guardian must file a report annually; the court will then issue new letters of guardianship.”
If it’s an emergency, two options exist for getting a temporary guardianship. With either, the court must find there is an immediate and serious danger to the person’s life or health, and that the person’s welfare requires immediate action in addition to the normal finding that the person is incapacitated. A temporary guardianship lasts for 30 days, though it may be extended for an additional 30 days upon a showing of good cause.
While 15 days of notice is required before the court may appoint a guardian in the normal course, only two days of notice is necessary before the appointment of a temporary guardian. However, the court may waive the two-day pre-appointment notice period if it finds that immediate appointment is necessary; if the court waives the two-day pre-appointment notice period, the petitioner must ensure that notices are sent within two days after appointment.
“A petition for a temporary guardianship is often coupled with a petition for a guardian for an indefinite period of time. Proceeding in this manner results in a seamless transition between the temporary guardianship and the guardianship for an indefinite period of time,” Shaw said. “The law does not require the two petitions to be combined and filed simultaneously, but I would encourage taking this approach if you believe a guardianship will be necessary for more than 30 days.”