On March 23, 2020, Daniel Prude was in a terrible state. After his brother reported him acting erratically, Prude was taken to Strong Memorial Hospital and given a mental health evaluation, but was released. Later that night, Prude’s behavior worsened; by the time law enforcement officers encountered him, he was naked and bleeding in the street. Although at first compliant with the officers, Prude began to resist, spitting at the officers, who placed a spit hood over Prude’s head and restrained him. He subsequently died. According to the medical examiner, Prude’s death was due to excited delirium, secondary to PCP intoxication. The grand jury found the officers involved were not criminally liable for Prude’s death.
This case highlights an all-too-common situation. There is something terribly wrong when people in crisis are injured or die in confrontations with law enforcement after they have been turned away from a hospital. Why aren’t people suffering psychological emergencies admitted and treated within hospitals?
Reasons They Are Let Go
In my experience, there are several primary reasons for such unfortunate situations.
There aren’t enough hospital beds. Since 1950, psychiatric hospital beds in the United States have decreased from 540,000 to 58,000. With insufficient beds, there is a continuous triage regarding who is placed in the hospital. In smaller, rural communities, the nearest psychiatric hospital might be hundreds of miles away or even in another state. With the exception of an emergency room or jail, there is no sanctuary for many people in psychiatric emergency.
Many seeking help are alleged to have committed crimes. Mentally ill individuals who have been detained by law enforcement are not welcome in many hospitals. And truthfully, hospitals aren’t set up to manage at least some of these people. As a result, people dealing with mental illness who are alleged to have committed crimes are sent to jail. Our jails have become our largest inpatient mental health services, but correctional officers are often unequipped to help profoundly ill individuals, increasing the chance of an encounter that will result in injury or death.
Treatment is expensive and time-consuming. Many people with mental illness, despite a multitude of attempts and services, simply don’t get better. With some conditions, care is not a matter of cure, but of mitigating symptoms and reducing suffering. Mentally ill people may require tremendous time and services to improve: I recall one case where a case manager worked several hours a day for eight months to get a single mentally ill homeless woman to accept a short-term stay in a motel room.
When an intoxicated individual manifests suicidality, psychosis, delirium or violence, guess who’s called?
People dealing with the effects of mental illness can be disagreeable. Some people will spew ugly names or racial epithets; they may threaten sexual assault. Some won’t follow through with treatment or will attempt to secure drugs simply to get high. They might be foul-smelling, aggressive or uncooperative. As a result, they are often sent back to the streets.
Drugs and alcohol complicate things. Many emergency rooms will not accept a patient if their crisis is substance-abuse related. Detox is the necessary first step, but it’s chronically underfunded and it certainly isn’t substance-abuse treatment. When an intoxicated individual manifests suicidality, psychosis, delirium or violence, guess who’s called? Police—and the police have nowhere to place such people if the hospital won’t take them, except back on the street or jail.
Some hospitals are adversarial toward law enforcement. Law enforcement officers will sometimes bring an individual to a hospital because they manifest—or claim—a serious mental health condition. I have observed police treated with either arrogance or outright contempt, with staff discounting the officer’s observations of the patient in the community. This can lead to hospitals discharging patients who would benefit from help.
There’s an acute lack of crisis respite beds. Not every person in psychological crisis needs to be in the hospital, even some who are suicidal. There are many people who frequently go into short-term acute crises. They can’t manage their own terrible emotions, and will react by overdosing on drugs, self-mutilating, or becoming suicidal or violent.
On the surface, such individuals may meet the criteria for inpatient hospitalization. However, there are cases where the same individual will transition out of crisis in an hour or two, becoming eventually calm, rational and stable. Such people should generally be discharged, the same way a hospital would handle a person with a shard of metal in their eye; once removed, you send them home with instructions on aftercare and check in later to ensure they are okay.
Unfortunately, protocols usually demand that, once admitted, a person is kept for 72 hours. In some states, it can be as long as five days. Many of these patients experience another breakdown—this time directed at the hospital. They assault staff or become suicidal again. This results in them being forced to stay in the hospital longer. Hospitals, particularly emergency room personnel, are well aware of this vicious cycle and may therefore refuse to admit the patient in the first place even though they are, in that window of time, dangerous to themselves or others.
What’s needed (and exists in too few places) are short-term crisis respite centers (CRC), where people are discharged as soon as they are emotionally stable. Individuals who are prone to short-term crises have a place to stay with trained staff so they can get through their immediate mental health crisis and go back to their home or a temporary shelter, rather than being hospitalized.
In addition, CRC provide law enforcement officers an alternative to jail for misdemeanor offenses where the subject seems mentally unwell. The officer can issue a bench warrant to appear later regarding the misdemeanor. If the subject is compliant with staff, they can stay for a time in the CRC; if not, they are detained in jail.
Consider the societal changes necessary to help those truly suffering from mental illness or chronic substance abuse. Not only will this require a tremendous amount of money—which should be additional to police funding, not deducted from—it will require, in many instances, evaluating existing law. Staff in outpatient clinics and hospitals will need far more training; some will need to combine the skills of psych techs and correctional or security officers within a single role. At least in larger cities, dedicated psychiatric units need to be established within the correctional system to handle the increasing numbers of mentally ill and substance-abusing offenders.
Beyond all else, we need to think seriously about what we view as personal freedom, at least when it pertains to standing by and allowing people to live in squalor, filth and delusion. The truth is, we will not really “leave such people alone.” When they become disorderly, obnoxious or threatening enough, the police will be summoned. The police will then interfere with their freedom, according to what’s permissible and possible. Would it not be better that this is done at a lower threshold—within a hospital rather than later in handcuffs? Or as in Daniel Prude’s case, and so many others similar, face down on the pavement, only a few hours following his discharge from a hospital where he would have been safe?