You've probably heard about Britney Spears' hospital stays, including the one in progress which has been extended another 14 days.
The California laws sound similar to those here in Louisiana, which are roughly as follows:

There are three possible criteria for committing a person against their will. Any one of these three can trigger the filing of an order of commitment by a physician, not necessarily a psychiatrist:
1. Danger to self. 
2. Danger to others.
3.  Being in a "gravely disabled" state.
"Gravely disabled" is a blanket term for any of a number of conditions that keep a person from functioning for their survival or wellbeing, such as eating, dressing and hygiene. They may have disorganized thinking, or paranoia, or hallucinations, or delusions, or delirium from a non-psychiatric medical condition.

The person is held while a psychiatric hospital is found and transportation is arranged. Sometimes there is a significant distance to travel to a facility that has an available bed. Meanwhile, the clock has started ticking with the moment of signing of the commitment order. There is a 72 hour window for a "coroner's deputy" (who must be another physician) to assess the patient and confirm or invalidate the commitment.

The ticking clock is also counting down 15 days, the time allotted for treatment. Should more than 15 total days of treatment be needed, the patient must sign his/her agreement to continue or the doctor will be forced either to release the patient, or to file a court petition seeking more time. Only a judge can extend the 15 days if the patient is not willing.

Now, where I work we frequently have patients who arrive believing that they are there for a maximum of 72 hours. Why? Because staff at whatever emergency room told them that. It's not true, and you can bet the ER staff  have been told many times not to say it, but they never seem to learn. It's easier for them to pacify the patient with this fiction than to try to explain the law, but it leaves us at the psych hospital to face the patient's wrath. Try to win their trust for therapy after that!

On some occasions we have had to let someone go at the end of their 15 days, despite their having not been fully stabilized to our clinical satisfaction. If they are not actively suicidal, or imminently dangerous to self or others, or are still unable to function, we can not hold confident expectations of winning more time in court so we can't impose on them any longer.

Sometimes by the end of 15 days they have gotten clearer in their thoughts and have started to have pretty good insight into their need for the care, and so are willing to go along if the doctor calls for more treatment time. Many other times they don't care about their longterm sanity, they just want out to resume their frantic pursuit of whatever business or pleasure they'd been chasing prior to hospital admission.

It's their right under the American constitution, regardless of whether or not it's a foolish decision. Have you ever considered that the constitution protects the right of citizens to make foolish choices? It's true...  Consider how little freedom there'd be in our country if people did not have the right to make foolish decisions... Who would be the arbiter of what everyone must do? (I know, there are those who would offer their services to guide us all.)

Patients also have the right to be at the hearing, and to have an attorney, and to speak  in their own behalf. To this end there is a state attorney in each region whose sole job it is to protect the rights of persons facing involuntary commitment to hospitals or nursing homes. I know, because I've seen in court, that they will shut the proceedings down if we fail to dot the "i"s and cross the "t"s.

Sometimes the patient is the one who makes the strongest case for their continued treatment by their own words or behavior. My late first wife, a psychiatrist, told me years ago about one client who was winning his case... until the moment he started peeing in the courtroom!

Any questions, class?

I've seen it done. It saves lives among people with treatment-resistant depression or mania. These lives are at risk for suicide because of the deep and endless misery of such conditions. Those with unremitting mania are also at risk for dying of exhaustion and a lack of sleep or food intake.

ECT is not what it used to be. Now it's done with less current, applied to only one side of the brain to induce the seizure. General anesthesia prevents muscle contractions that might cause injury.  The doctor twiddles some dials, pushes a button and the patient's toes point down. That's how you know the seizure happened. They come out of it later with temporary amnesia, a headache ...and the absence of their mood symptoms. They feel better! I call it "hitting the reset button".

There are typically 2 or 3 sessions over 7-10 days, with a single booster some months later. Click the link below to read more.


Electroconvulsive therapy

The brains of persons with BPD appear to show less than average activation in the impulse control region.

I do not believe that fully accounts for the condition because a simple deficit in impulse control would not produce the manipulative behavior. There is something more subtle going on here. I think the reduced activity is a byproduct of the condition rather than a cause.

Borderline Personality Disorder is as yet poorly understood, though much studied and discussed. Some leading theories presume that it begins with a disruption or trauma during the first 6 years of life or earlier, such that the person grows to adulthood with a somehow incomplete or impaired awareness of "boundaries" between him/herself and others.

When you can't tell where your feelings and desires end and those of the next person begin, the result is often seen in turbulent, chaotic relationships and manipulative or unpredictable (even self-contradictory) behavior.

It is a deeply distressing experience for individuals thus afflicted.

The research to which I have linked above is only a beginning, but the article suggests that the reader hold some compassion for people with BPD because it may eventually be shown to have neurological origins. In other words, they don't choose to be this way.
I also say they don't choose this, and recommend compassion.

As to how to express compassion to someone with the disorder, that is not so simple as "being kind". In a seeming paradox, the kindest thing one can do for a friend or relative who has the disorder is to set and firmly keep some behavioral lines that they must not cross. Easier said than done... Some BPD sufferers can be pretty relentless in their demands for attention and reassurance. They may be terrified that you will abandon them forever.

Keeping your breathing space will challenge your own sense of self at times, so you'll have to do some soul searching to not be pulled emotionally into an exhausting effort to fill a bucket with a hole in the bottom (so to speak) or be driven to unkind acts. Either option would be extreme; fruitless in the first instance or potentially harmful in the other.

If you can walk that tightrope, your friend may benefit. If you fear you can not do that, it's less unkind to let the relationship go...

For more info:
BP Central
Dialectical Behavior Therapy

By being healthy yourself!

Even people who have mental illness can manifest emotional health if they practice kindness toward themselves and a determined effort to do the behaviors that maintain health.

How do you attract an unhealthy mate? By looking for someone who will make you happy.

Nobody can do that.

Except you.

How?

By looking at yourself and seeing the many ways that you TRY TOO HARD!

You can't get happiness because it is not out there in your environment. It's inside you, it's your natural state, but it's just covered over by all these habits of running away from things that scare you, grabbing at things you want, trampling other people to get to a goal...

It's your natural state, your birthright....

Problem is this confusion we're taught to have about external vs internal. We react to things we think we see outside ourselves that threaten or enhance our happiness. But in fact we are reacting to our feelings about these things, trying to fight our feelings by fighting the world. Kinda like stopping Joe by hitting Sam. Doesn't work. Makes things worse. Makes us (and Joe and Sam!) confused...

...or trying to get good feelings by getting some goodie like a double fudge ice cream cone or a Cadillac or a sexy, vibrant partner...(OOPS! Why didn't it work? Maybe I just haven't found the ultimate goodie yet....)

"Well, goshdurn it, Havoc, what do I DO??"

Just stop! Be still a moment. Look at yourself. See the illusions...

 

Psychotherapy research: "The patient and painstaking process of gathering data, analyzing it statistically, then deriving techniques for emotional healing and increase of awareness, until what is achieved is the reinvention of Buddhism."

 

 

 

 

In other words, "reinventing the Wheel of Dharma!"

PERSONALITY DISORDERS are characterological disorders, not disorders of thinking or mood. They are generally believed to result from some deficit in a person's sense of self, possibly involving some impairment in the ability to form emotional bonds with others. Self concept or personal identity develops in the first few years of life. This process of development can be interrupted or afflicted by traumatic events during those years, hence the deficit.

Some possible traumas include: a medical illness of the child or the child's adult caregiver, being the victim of abuse, witnessing a serious accident or violence, or possibly a prolonged absence or emotional withdrawal of the primary caregiver...

The treatment of any kind of personality disorder tends to be a slow, labor-intensive process which insurers are reluctant to fund. The results are often modest, and may be abruptly halted by the client who may find it to be too much work, or too threatening. In cases of ANTISOCIAL or NARCISSISTIC personality disorders the client may resist participating in therapy at the outset, believing it to be entirely unnecessary. Many therapists find this work tiresome and frustrating, leading them to refer such clients to other practitioners.

BORDERLINE PERSONALITY DISORDER is a particular personality disorder that features a pattern of instability in interpersonal relationships, unpredictable or dramatic behavior, rapid shifts in mood, a poor sense of the emotional boundaries between self and others, and emotional neediness.

Treatment may involve judicious use of anxiety relieving medications, but primarily should be talk therapy with the teaching of coping skills. Overuse of anxiety meds is a potential pitfall to be avoided. The therapist should set firm, clear emotional boundaries and maintain them without exception. The client needs this because it helps her (him) know where she stands in the therapy relationship. The therapist will use her (his) own sense of self in choosing how to demonstrate healthy interpersonal behavior to the client. In this way the therapeutic relationship becomes a model to the client for establishing other healthy relationships.

Coping skills coaching will have the goal of helping the client learn to identify and correct their tendency to interpret the behaviors of self and others as being "all good" or "all bad". Constantly, patiently, the therapist should direct the client to be aware of this unealistic tendency in themselves and to use the awareness to find a more realistic middleground interpretation of others' behavior.

The client may attempt to borrow (or even steal!) the identity of significant others in their life, including that of the therapist. Those who find themselves the focus of this person's attentions may feel that they are being stalked. Redirect the client to focus on defining him(her)self to establish a personal identity that is neither "all good" nor "all bad".

Unlike narcissistic p.d. or antisocial p.d., borderline p.d. is generally distressing to the afflicted person. Their instinctive struggle to fill the gap in their sense of self may consume their time and energies, to such an extent that they will interpret every situation and relationship as revolving around them personally.

If you choose to be in an ongoing relationship with a person having borderline p.d., you should be prepared to be this person's emotional anchor and should not expect them to reciprocate. Look for other compensations in this relationship, such as monetary wealth. Many actors and actresses have borderline p.d., which equips them to excel at their art, even as it afflicts them emotionally and interpersonally. The ability to assume a new "personality" on command can be lucrative!

BIPOLAR AFFECTIVE DISORDER, formerly called Manic-Depressive disorder, is primarily a disorder of mood (affect).

It features extremes of mood, such that a person who has it experiences periods of  depressed mood and/or periods of a very high, elated mood, which is called the "manic" state. They tend to talk nonstop, unable to finish what they want to say before the next fabulous thought shoots from their brain to their lips. The result is they sometimes don't make much sense to the listener.

In the manic state a person may go without sleep for days, may have little sense of needing food, experience a rush of ideas and grandiose plans. They may get irritable when someone interferes with their plans, which are sometimes wildly impractical, or hazardous. If you've ever used "speed" you'll have a sense of what mania is like.

This mania may alternate with a state of depression, wherein a person may feel sad, hopeless, even suicidal. Like any person with simple depression, they tend to lack energy and motivation.

Sometimes, but not always, bipolar disorder may involve psychotic features such as auditory hallucinations, delusional thinking or disorganized thinking. This is especially likely when there has been extended sleep deprivation. If allowed to continue, manic sleep deprivation is dangerous,and can lead to physical collapse. For extreme cases only, electroshock can be a lifesaver, and is a far safer and more refined procedure nowadays than it was in decades past.

Bipolar disorder is usually treated with a mood stabilizer such as lithium or depakote. Lithium works wonders for many, but must be monitored closely with regular blood tests to avoid getting a toxic level in the blood. Depakote generally has fewer side effects. There are other mood stabilizers, and the choice of which to use is best left to a psychiatrist, not a clinical social worker such as myself.

I used to work as an experimental technician for a scientist who had bipolar disorder. We did experiments involving the effects of various substances on human aggressive behavior. He was of course a very intelligent man, and had a better quality of life than you might expect. He took his medications, but about every year and a half he had to be hospitalized. Perhaps he was making the common mistake of convincing himself he no longer needed medicine....

 

SCHIZOPHRENIA is a very different disorder, a thought disorder featuring PSYCHOTIC symptoms: disorganized thinking, hallucinations auditory or visual, and delusional (sometimes paranoid) thinking. It is NOT multiple personality disorder. The treatment for it is mainly antipsychotic medications such as zyprexa and seroquel, numerous others. There may be mood changes with schizophrenia, but the psychotic symptoms predominate. If you have ever used hallucinogens such as LSD, psilocybin mushrooms, or peyote you'll have a sense of what schizophrenia feels like. Tripping can be fun, (though sometimes terrifying) but would you want to live that way your whole life?

MULTIPLE PERSONALITY DISORDER is highly debatable as a genuine diagnosis. It is considered by many to be merely a variant of BORDERLINE PERSONALITY DISORDER. My late wife, a psychiatrist, said this was the case. She did not indulge in summoning the various "personalities" in such patients, but would insist to her clients that they were in fact one individual, and that they could and should function as such. If you saw the movie "Sybil" you may recall that though Sybil's psychiatrist used a different approach, the goal was essentially the same: integration. 

PARANOIA clinically is a feature of a thought disorder. Being self-conscious or scared is not true paranoia. Typically, paranoid thinking involves a delusional (unreal) belief that others are acting to harm oneself.

Persons afflicted with bipolar disorder or schizophrenia can not help it, and all your efforts to use reasoning to relieve their symptoms will not help either. They are not people of natively weak character or bad morals any more than are people in the general population. Their parents didn't cause it by raising them wrong. They are just unfortunate enough to have inherited something wrong in their neurochemistry. 

 

...in teaching mode...

Client self-determination is a core value in social worker ethics. A therapist is expected to refrain from over-riding a client's right to make informed choices for herself (himself). There are a number of reasons that therapy goes astray when this principle is abandoned.

This is respect for the client as a human being possessed of free will.

It is tempting to the therapist to help him(her)self feel better by fixing the client's problem by simply taking it over, doing the work and then handing the client a neatly packaged solution. But it robs the client of the chance to experience a success or to learn something from a "failure". If you step in and fix it, your actions will speak louder than your words, and your actions say to the client,"I don't think you can handle this."

So a therapist "leads while walking two steps behind". You have the map, you know the roadsigns, you go with them as they choose which fork in the  road to take, even if it looks like a wrong turn. Then you process the experience with them: "How did that work out? How could you have done it differently? ...and let them choose again how to proceed.

When the client gains enough confidence to take leave of you, your part of their journey is over. Your role is to congratulate them on their accomplishment and let them go. Maybe their path will not be what you would have chosen for them, but it will be THEIR path. You can't walk it for them.

 

How to confront someone's behavior:

1. State what you have observed about the pattern of behavior.

2. State how that behavior is inconsistent with the things that person has said about getting healthy, or how it is inconsistent with their values. Example: "You told me 2 weeks ago you would stay sober, but today I see a beer next to your plate. What's going on?"

Notice what wasn't said: No accusations or shaming talk, just a request for clarification.

In this way you call upon that person to resolve the gap between what they say and what they do. The simple act of bringing it into their awareness without shaming or blaming leaves them on the spot to change. If you speak, look or sound accusatory you just give them an "out" for discounting what you have said, or an opportunity to focus on defense or retaliation instead of the real issue: their behavior.

3. You can go on to ask them for a specific change: "I want you to stop drinking completely, because you'll have a better quality of life that way, with fewer DUIs and fewer times being committed to the psych hospital. I feel terrible when I have to call the sheriff to take you to the emergency room." Being clear about what you want is helpful. For added effect you can state your emotional reaction, as in this example. ("I feel terrible when I have to call the sheriff...)

You can use this approach for all kinds of confronting, even for more trivial matters than this example. Just remember, your attitude is to be supportive, not insulting or blaming. Never invite a human being to dislike him or herself.  If you do you won't get what you want from them, not in any way that is real.

Does this approach give the desired result every time? Of course not! Ultimately, people will always do what they CHOOSE to do. But the chances are definitely better this way, and when you don't use coercion you can follow up later by giving them credit for choosing to change their behavior.

 

What is it with these trisexuals? Can't they just stay in the closets instead of parading their stuff around? No telling where this could lead if the rest of us don't put a stop to it!......quadrisexuals? What is this country coming to?

 

 

 

"Restroom for Heterosexuals, Homosexuals and Bisexuals ONLY!"