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When Going to the Hospital Is Just as Bad as Jail

This story was published in partnership with The Marshall Project, a nonprofit news organization covering the U.S. criminal justice system. Sign up for their newsletter here.

The ambulance was rushing to a psychiatric hospital, with Y. strapped to a gurney, asking the medics: Why? Why were they taking her there?

Just that morning, she’d noticed her speech quickening—a symptom of her bipolar disorder—and made an appointment with her doctor for the next day to adjust her medication. She knew she was “wavering,” but was being proactive so it didn’t disrupt her life. (She asked to go by her middle initial only, concerned that speaking openly about her mental illness could affect her current job search.)

Y. had called the police herself that night, to report that her children had been out with her ex-husband and never came home. But as soon as cops learned of her diagnosis, she said, they treated her like a “crazy Black woman,” rather than a mother understandably frantic about her kids. She claims they handcuffed her, called an ambulance, strapped her down, and took her to John George Psychiatric Hospital outside Oakland, California, against her will.

Officers weren’t arresting her. They were detaining her under a state law that empowers police and other first responders to take people who they think are a danger to themselves or others to a mental health facility.

At the hospital, Y. claims, a nurse injected her with antipsychotic drugs while she was restrained. She says she blacked out, only to awaken as nurses shoved a needle into her other arm. “It felt like I was being punished, like I was in prison,” she said. “How is this supposed to be healthcare? It was by far the most traumatic experience I’ve ever had in my life.”

In this year’s national reckoning over racial justice and policing, many have asked why armed officers are most cities’ default response to someone in crisis. Those interactions can have fatal consequences: this spring, police in Rochester, New York, asphyxiated Daniel Prude while he hallucinated, and in October, Philadelphia police shot and killed Walter Wallace Jr., a Black man with Bipolar disorder who was holding a knife. Cities across the country are considering removing law enforcement from many of these encounters, to prevent violent outcomes and keep people with serious mental illness out of county jails.

But simply diverting people from jail to a hospital isn’t enough of a solution, lawyers and activists say. Many who have endured a short-term hospital stay say the experience of being held against their will in a psychiatric ward was as traumatizing as being arrested, and didn’t connect them with any follow-up treatment. Along with creating separate 911 response teams, activists have called for reinvesting police funds in community organizations to support people with mental illness long before they’re in crisis, being shot at, or pinned to the pavement by police.

Y. filed a complaint with the Oakland Police Department over what she called a rough, unnecessary hold, but the department’s Internal Affairs Division decided their officers had acted legally and in line with department policies. Spokesperson Terry Lightfoot for Alameda Health System, which runs John George Hospital, said in an email the hospital “prioritizes [the] least restrictive forms of treatment” and uses injections only if there’s an immediate safety concern for the patient or others in the unit. Only about 10 percent of emergency patients receive involuntary medications.

Just as communities of color experience more police violence, they also face disparities in the existing mental health system. Alameda County, California, has the highest rate of psychiatric holds in the state—over three-times the California average. Black people make up over a third of those brought to the hospital’s emergency psychiatric ward, but just a tenth of the county population overall.

“Right there, that tells you that something is dramatically wrong with the system,” said Lorna Jones, executive director of Bonita House, an Oakland-based community mental health organization.

This summer, the legal group Disability Rights California sued Alameda County and its health system for allegedly forcing mostly Black residents into a series of disruptive short-term hospital stays. Of the more than 350 people who had been held in John George’s emergency unit at least 10 times, over half were Black. Some had been hospitalized over 85 times. The lawsuit claims the county is violating the Americans with Disabilities Act, by failing to provide enough resources to keep people with serious mental illness from being unnecessarily locked away in a hospital.

People of color are more likely to be over-policed and less likely to have access to quality mental health care. Lawyers say the high involuntary detention rates stem both from first responders being too quick to hospitalize someone, and the community failing to provide alternatives for people who need help.

“How many of those people could be served where they are, or in a more community-based system?” said Kim Swain, senior counsel with Disability Rights California and one of the lead attorneys on the case. “Usually people just get released after spending days in a waiting room.”

Alameda Health System has filed a motion to dismiss the complaint, claiming it is not responsible for who ends up in its care or whether there are sufficient community resources to avoid hospitalization. Attorneys for the hospital also claim that allegations of racial disparities in patient care “are superfluous, inflammatory, and distract from the central issues … ”

Lightfoot, the Alameda Health spokesperson, said the hospital refers discharging patients to county programs, notifies any existing case managers, and at least provides a community resource list if someone declines to be connected to follow-up care. In response to claims about long wait times, Lightfoot said that “all patients are immediately assessed by a psychiatrist on arrival and treatment is initiated at the same time.”

The county has not yet filed a response to the suit. In an email, a spokesperson for the Alameda County Health Care Services Agency said she could not comment on pending litigation and declined to answer other questions. She noted that the county launched its pilot Community Assessment and Treatment Team this summer, which will send licensed mental health clinicians to some 911 calls. Reducing the number of involuntary mental health holds is a stated goal of the program, by sending trained professionals who can refer people with mental illness to other supports and services.

Currently, police often respond to those difficult calls, and they have limited ways to handle them.

Sgt. Doria Neff, supervisor of the mental health unit for the Oakland Police Department, said officers respond to 40 to 50 mental health calls a day—a significant increase since 2010. Roughly half of them end in an involuntary hold.

“Officers have to consider someone’s behavior and leaving them in public while attempting to predict if the delusions, hallucinations, paranoia and/or anxiety is controllable,” she wrote in an email. “Officers don’t work in a controlled environment […] Psychiatric detentions are unpredictable and require some interpretation based on the person’s level of cooperation.”

The lawsuit has precedent. In the mid-1990s, Lois Curtis and Elaine Wilson—two women with mental illness and intellectual disabilities—sued Georgia state agencies for keeping them locked in a psychiatric hospital, even after doctors found the women were ready to be released to a community program. The state appealed, saying it was a lack of funding and not outright discrimination that kept the women institutionalized. But in 1999, the U.S. Supreme Court ruled in favor of the women, finding that Georgia discriminated against them by failing to provide adequate community options.

“Institutional placement of persons who can handle and benefit from community settings perpetuates unwarranted assumptions that persons so isolated are incapable or unworthy of participating in community life,” Justice Ruth Bader Ginsburg wrote in the majority opinion. Since then, states like Mississippi and Ohio have been sued for similar violations.

The Alameda case is among the first to focus on how this disproportionately hurts communities of color. Black men, the complaint notes, are significantly more likely than other groups to end up “involuntarily institutionalized in the wake of a mental health crisis call.”

It’s coed, so I was getting hit on. There’s people everywhere.

— Cat

Ira Burnim, co-counsel in the case, said the Black Lives Matter movement has helped bring more attention to these disparities. Research suggests Black Americans are overrepresented in psychiatric emergency rooms and under-served by voluntary, community-based mental health support.

“It’s a pretty good bet that in other jurisdictions as well, the group of people who are seriously mentally ill and show up repeatedly in emergency rooms or crisis services, in jail, or on the streets homeless are disproportionately people of color,” said Burnim, who is legal director for the Bazelon Center for Mental Health Law, a national advocacy organization.

States and cities have long struggled with a dearth of mental health care funding, and whether to put that limited money toward more in-patient psychiatric beds or community mental health care. This tension has only gotten worse during the pandemic, now that government budgets have been gutted, some psychiatric hospitals have become COVID hotspots, and mental health issues like anxiety and depression are on the rise.

This lack of funding is particularly a problem in places like Alameda County, located east of San Francisco, where homelessness has grown by over 40 percent since 2017. Studies show that stable housing can significantly decrease the use of emergency psychiatric services. People who are homeless are more likely to encounter police, struggle to maintain their medications, lose contact with healthcare providers, and move frequently between jail, emergency rooms, and city shelters. Nearly half of the people experiencing homelessness in Alameda County are Black.

The county is unique in that most people on a psychiatric hold go to John George—in other places, patients might wait for hours in an emergency room at a medical hospital before being transferred. But that system has meant the emergency ward is often crowded, nurses and patients say, which can contribute to the stress and trauma of being detained.

Cat, who asked to go by her first name only because she works in the mental health field, said she waited nearly two days in January for a full consultation with a psychiatrist at John George, which she claims lasted five minutes. “I started freaking out, [wondering] am I just going to be here for a week, waiting for a doctor?” said Cat, whose family had called 911 after she texted suicidal thoughts. “It made it so much worse. I missed work, you have to eat and sleep on the floor. It’s coed, so I was getting hit on. There’s people everywhere.”

Nurses say overcrowding and understaffing has also put them at risk of assault and makes it harder to provide quality care. “We would just run out of floor space,” said nurse Troy Nixon, who has worked at John George for 27 years. “It was very unsanitary, we certainly couldn’t provide any kind of treatment. It was basically breaking up fights all the time.” Nixon says conditions have improved since COVID-19 hit, prompting the hospital to discharge people more quickly and keep numbers low.

Lightfoot, the Alameda Health spokesperson, said 25 to 30 patients is the maximum the emergency unit can serve now and maintain social distancing. After their initial assessment, most patients receive their next full evaluation with a psychiatrist within three hours of arriving at the hospital, he wrote.

Any crowding that has occurred is a sign the community needs more hospital beds and more effort to prevent mental health crises before they happen, said Dr. Scott Zeller, a former chief of psychiatric emergency services at John George.

“It’s tough to blame the one place providing these services because they’re too busy,” he said. “The majority of people are there because they are in very serious psychiatric emergencies and there might not be a lot of other options for them. Anything we can do to minimize the need for people to be on [involuntary holds] is a great thing.”

Alameda County is one of many localities creating alternative first responder teams, especially in the wake of George Floyd’s death. Organizers say the teams will be better suited to de-escalate psychiatric crises and discern who actually needs to be hospitalized. Nixon, the mental health nurse, said he sees many people arriving at John George for vague reasons like walking into traffic—sometimes five such cases in a 12-hour shift.

“People get brought to us for the most ridiculous reasons,” Nixon said. “We serve as a shelter, a drug program, a jail. It’s a multilayered social problem that is all sort of being placed on John George to fix.”

The county has also opened a 10-bed, 24-hour crisis unit, known as Amber House, to provide voluntary short-term care for people during a mental health episode. Other cities, like Houston, have also established voluntary mental health centers, where police can bring people with serious mental illness who were arrested for low-level crimes.

For Y., the brief encounter with the hospital haunted her long after she was released. “It just scared me, that they can pull you off the street for anything and they’ll take you to John George,” she said. She started having nightmares about being held down and injected with drugs. “[They] harmed me more than they helped me. It put me into mania.”

She still worries a future mental health episode—a common occurrence even when people take their medication—could land her back at John George. Before that happens, she says, she will ask someone she knows to drive her anywhere else.

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