Imagine, if you will, three people. Any three people. Picture their hair, their clothes, the color of their eyes. You can even make up names for them. Take a moment to let them come to life in your mind. I wonder, what mental health challenges did you come up with for these individuals? Even if you didn’t think of this attribute yet, I’d suspect you are now. Chances are, you’re afflicting each of them with something different. Depression, PTSD, schizophrenia, it’s up to you. We’re still playing make-believe here. Naturally, the mind wanders to afflict our imaginary friends with any number of hardships – cancer, diabetes, heart disease.

Let’s say each of these individuals had a crisis with their medical condition and had to go to the hospital. It should be obvious that we wouldn’t provide the same treatment to each patient. Therefore, it would make logical sense to treat each patient experiencing a psychiatric crisis based on their particular condition(s) as well. Unfortunately, this is one of the most critical problems for mental-health patients under the current system. (Note: most counties and hospitals in California refer to the system I will be addressing as “Behavioral Health” but I believe this comes with a stigma that implies psychiatric or neuro divergence is best suppressed with ‘appropriate’ social behavior.)

Mental Health America, a leading non-profit mental-health advocacy group, states their official position on involuntary mental health treatment is that it should occur only as a last resort and should take into account the decisions of the patient regarding their care. They further go on to state, “effective protection of human rights and the best hope for recovery from mental illness comes from access to voluntary mental health treatment and services that are comprehensive, community-based, recovery-oriented and culturally and linguistically competent” (“Position Statement 22”). It’s clear that these mental-health experts agree that care should be patient-oriented. The fact they need to say this at all leads one to believe the current system is something other than the caring, positive environment they hope for.

Sadly, the California Welfare and Institutions Code 5150, the law under which individuals are able to be “detained” against their will under vague and subjective pretense by an under-qualified individual, is anything but comprehensive and recovery-oriented. This statute sets standards for a minimum quality of care that can be considered primitive-at-best. The law is written not for the benefit of the individual being imprisoned, but for the protection of law enforcement, medical personnel and government institutions. Because such a low standard of care is required, many facilities, especially those under government contract, provide only the minimum quality of care. This can potentially cause further trauma or deterioration of the patient’s condition.

Dr. Dinah Miller explores this idea in detail, noting both the quality of care provided to patients as well as the stigma attached to emergency psychiatric care. She notes that most emergency departments do not have trained personnel on-site at all times, if at all. At best, she says, “the most crucial and controversial decision in psychiatry often falls on the shoulders of an emergency physician” (Miller). To be clear, these individuals are trained in the broadest range of medicine, with most not having a specialization and having not gone through psychiatric training since med school, which could have been decades ago, back when homosexuality was in the DSM.

When discussing those emergency personnel – and this can extend to police and EMS employees as well – Dr. Miller pays special attention to the stigma attached to patients in need of emergency psychiatric care. She compares the typical mindset of emergency departments, which mirrors society as a whole, in thinking that forced care is a good thing, often taking a “better safe than sorry” approach. She compares this with a viewpoint that echoes the position of Mental Health America, stating, “If doctors start off with the assumption that forced care is potentially traumatizing in a way that leaves some patients with years of distress, then the threshold for committing patients to involuntary treatments is significantly altered” (Miller).

In California, statistics emphasize the use of the ‘shoot-first’ approach to mental health care. The per-capita instances of involuntary hospitalization are higher than any other state, ten times that of the national average. Since statistics don’t show a higher rate of mental health diagnoses in California, one could infer from this data that the state is applying involuntary ‘treatment’ at a significantly higher rate than other states (Lee and Cohen).

It’s not just the rate of hospitalization or standard of care that is a concern, although being denied access to food, exercise, sunlight and self-care products can potentially be traumatizing as well. What Dr. Miller and countless others are concerned with is the presumption that mental health patients are unable to make rational decisions regarding their care and are potentially violent. Medical and psychiatric care providers having this mindset while considering their own legal and malpractice liability often leads to decisions being made that are not in the best interest of the patient.

Roy Richard Grinker, a mental health anthropologist and fourth-generation psychiatric specialist, goes into extensive detail about the economic and cultural factors at play in his study on mental health stigma throughout history. He notes that throughout the medical field, human bodies are the medium that the industry capitalizes on. Because of this, he continues, bodies and their diagnosis must be broken down into mechanical and utilitarian terms. He states, “When bodies become sick in capitalism, they become vulnerable to technologies like pharmaceuticals and reimbursable diagnosis” (215). This creates and encourages a profits-over-people attitude throughout the entirety of medicine and psychiatry.

We can discuss emergency psychiatric care from a legal and academic standpoint endlessly and still not find the information needed to create solutions to this problem. In order to paint a complete picture of how the involuntary detention process can be traumatic to individuals who are already in a fragile state, we need to listen to the voices of the actual patients. I’ve chosen to explore this topic because I’ve been personally traumatized by the experience. Over time, I’ve chosen to drop the stigma and discuss my mental health openly. In doing so, I’ve heard the stories of others who have had similar traumatizing experiences. From being left in a waiting room with no food,water or bed for thirty-six hours to being restrained and strangled by staff for completely innocuous actions. Others tell stories of being forcibly medicated and denied medical care, comparing their treatment to that portrayed in movies about early twentieth-century asylums. One oft-repeated form of trauma experienced by many patients is the uncertainty of what will happen to them and even if/when they will be able to leave. 5150 is not a crime in California, but more often than not, individuals feel more like prisoners than patients (Phernelia; Jefferson; Meagley).

These stories weren’t told by those having psychotic breaks. Nor those with schizophrenia or psychosis. These are just a few examples of the standard of care received by countless everyday people who have done nothing more than admit to thinking about suicide. None of these patients were violent or unable to make reasonable decisions. These experiences occurred because the stigma attached to psychiatric patients by staff is built on the assumption that they (we) are all violent.

In order to break down the stigmas and provide care that is “comprehensive, community-based and recovery-oriented” it’s imperative that the system of involuntary hospitalization be reformed to be used as a last-resort, as many experts believe it should be. Rewriting the legislation and changing the entire process is beyond the scope of this paper, but I would like to explore an alternative form of in-patient treatment that is dynamic to the needs of each patient, creates a community-oriented support system and encourages enrichment and overall wellbeing.

5150 is often summarized by law enforcement, less than tactfully, as “not in control of one’s facilities.” This was how it was described to me by the Sheriff’s Office during my training, without any explanation or clarification of what that means. For the sake of this solution, it’s important to note the “not in control” part of that statement. For many people, especially those who are not regular users of the system, they often end up there because the stressors of life have become too much to cope with, as we saw in the personal experiences shared above. Why, then, would it make sense to put them in a situation where they have even less control without providing any tools for coping or recovery?

The clinical environment of apathetic nurses, inept doctors and locked doors provide benefit to those staff members and corporations who wish to profit from the misfortune of others, but not the patients they claim to exist to serve. In my experience, the only people who care about the well-being of the patients, the only ones who will have honest discussions about mental health without judgment, are the other patients. With that in mind, it seems like a patient-centric care model would be an ideal solution for those patients who need a support system.

While the clinical model may be necessary for the most distressed patients, this can be accomplished by hospital behavioral-health departments, eliminating the need for short-term Behavioral Health Centers. Patients needing to recenter and reconnect would benefit from time in nature with enrichment activities and surrounded by those who care about their welfare. My solution – the first half – is a facility that puts the patient in this environment and encourages them to take advantage of the program before they’re kidnapped at gunpoint.

The prospectus is over twenty pages for this facility, but to summarize in just a few paragraphs, the care center would exist on a small plot of land, five or ten acres, in the mountains or other natural environment, as best fits the region. Housing would exist in small cabins, yurts or the like. This is important, as it will provide the participant an opportunity to retreat in the event they need solitude, but without locked doors and hospital beds.

Instead of cramming several dozen patients into one facility, we would limit our attendance to maybe a dozen individuals. Since the operation costs would be reduced exponentially, additional facilities could be created as needed instead of attempting to squeeze more and more people into the existing system, as is the case now. Staffing would be minimal, one facilitator is all that would be needed to operate the center. The majority of the ‘work’ would be done by the participants. Not that patients would be put to work, but they would be responsible for each other – as caring for others can be helpful to many struggling with mental health. In fact, my own observations have shown that many psychiatric patients are caring and sensitive individuals who often feel overwhelmed or overextended in their relationships because they have learned to put the well-being of others ahead of themselves.

Each day, different participants would be given the opportunity to take responsibility for different aspects of the daily operations. They may be tasked with planning and preparing meals for the other participants, taking care to accommodate the dietary needs of the other participants. Another individual may be in charge of enrichment activities, such as art, music or gardening. Everyone has their own passions and skills and they would be encouraged to share these with others. It could be that they inspire fellow participants to take up a new activity that could provide long-term therapeutic benefits. Most importantly, when participants care for each other and are cared for, they may feel less alone in their struggles. For some, it could be the first time in their lives that they feel cared for or like they can contribute to others on their own terms. With the stigma attached to mental illness, it’s no wonder so many lack a support system, having been abandoned or admonished by friends and family throughout their lifetime, always being told that there is something wrong with them. For once in their lives, they need to hear that they are not something that needs to be fixed. What needs to be fixed is the way that we care for each other and they will have the opportunity to lead by example instead of being told how to behave as, no doubt, they’ve heard for years.

I’d love to get into the logistical details and day-to-day operations, but there’s still a completely different solution that should be addressed. Since the one-size-fits-all approach doesn’t work in the current system, it would be illogical to argue that my proposal would be the only solution. Although it is intended to grow organically around the needs of the individual participants, it doesn’t consider those who wouldn’t be successful in this environment – but also would not benefit from the clinical environment.

While many mental-health patients may be struggling because they lack a support system or coping mechanisms, this doesn’t take into account those who would benefit from a disconnect. It could be that someone is so overwhelmed from caring for others that the last thing they need is to be put in that same position when they should be recuperating. Please note, unlike clinical facilities, participants will not be forced to participate in anything that they feel is not in their best interest.

My inspiration for the second inpatient facility is inspired by Japanese business hotels. It could be that all someone really needs is to be left alone for a few days. They could be overworked and overstimulated and some time in a private location where they don’t have to answer to anyone, yet are still provided with options for support and coping mechanisms that they could take advantage of as they see fit.

Without becoming too prison-like, participants would be assigned to a small, private room designed to take advantage of technology instead of relying on human-based interaction. This could also benefit those with anxiety disorders or on the autism spectrum, who struggle with person-to-person contact. Through the use of video screens, lighting, sound and other equipment, participants may choose from a variety of therapeutic options, from light-and-music therapy to EMDR to video or text chatting with mental health specialists or other patients. There is no reason this needs to be restricted to just the local facility, either. Those who may feel embarrassment in participating in peer-therapy with someone from their own town could chat with a participant halfway around the world.

Participants would have access to a variety of beneficial media, such as self-help books, topical novels, inspiring or thought-provoking movies and television, and music, all curated by mental health experts in collaboration with participants.

Key to both of these systems is listening to what people say works for them and building future programs around that feedback, versus telling the patients what is best for them – often erroneously. Believing that a nurse with only a few months of training would know better than someone who has lived with their condition for years or decades is, at best, silly. Yet, the entire system is based around having under-qualified individuals put in control of the lives of those who are most in need of individualized and thoughtful care. It’s time we took control of the mental health system from the bureaucrats and corporations and put it in the hands of those who know best about how to deal with mental illness without coloring everything with stigma – the patients. We should keep in mind that although someone may be having an episode of suicidal ideation that would benefit from immediate care, these patients deal with these feelings day in, day out, for decades, which means that for many patients, they successfully cope with these difficulties 99.99999% of the time, which makes them infinitely more qualified than anyone basing their ‘expertise’ on that one week of nursing school ten years ago where they read about abnormal psychology.