AB 348, Chu, extends to licensed psychologists release authority from involuntary detention without expanding their scope of practice.

Supporters argue:

that since psychologists can admit and treat they should be able to discharge.

that allowing more people to be discharged might shorten stays

that patient-psychiatric contact might be briefer than patient-psychologist contact and thus the psychologist might have a more informed discharge assessment.

My personal experience in 1987 was that the inpatient treating psychologist

ignored my testimony about my several year experience with medication, refused to review lab work prior to the hospitalization, when an immediate positive blood test wasn’t within the recommended norms accused me of "cheeking" the medication, prescribed a (humiliating) liquid form, and increased the dosage to what for me was a toxic level. (Note: I’d never heard of "cheeking" until fellow patients explained and taught me how.). His order for PRN sleeping medication was allowed only in numbing 40 mg dosages, not the 10 mg which was helpful for me. Extra-pyramidal side effects of akathesia and swelling of my feet and lower legs were ignored. The psychologist used the title Doctor and neglected to tell me he was not medically certified. He also neglected to tell that to my outpatient psychiatrist who therefore did not intervene with the medication management, and the psychologist breached my confidentiality in his contacts with that person. The psychologist’s relationships with my family, as later reported to me, were disrespectful of me and dramatically negative about prognosis. Even though this was a while ago, I still feel the shaming, frustration, and anger at the disrespect.

The solution to overcrowding on psychiatric wards is not lowering discharge standards for early release but raising intake standards, having fewer admissions, providing interventions before situations escalate to this level. Early discharges frees up more beds and facilitate forcing even more people with psychiatric disabilities into hospitals, with an arguably shorter stay. This solves the wrong problem. Unseemly lengths of stay might be better managed by the payors and insurers. This effect of this bill contradicts the values of community treatment and works against Olmstead by making it easier to hospitalize.

The paucity of patient-psychiatrist contact might be better managed by requiring more medical and psychiatric involvement, rather than substituting the judgement of non-medical personnel. Other patients, psychiatric technicians, and nursing staff all also spend more time with patients than do the psychiatrists. Might we recommend they also have input into discharge assessment or authority?

Many other than psychiatrists and psychologists can recommend forced treatment - social workers, therapists, peace officers, ... . Should they all also have discharge authority?

Surely this release authority does expand a scope of practice, determining that further inpatient treatment isn’t medically necessary.

More broadly, this legislation deems people with psychiatric disabilities as not worthy of the same level of medical care as other hospital patients.

There's a great deal of research showing that people with severe mental illness do not get good general medical care, and that their chance of dying is higher as a result of medical problems. They have a high rate of undetected and untreated medical problems. Their chance of dying from medical problems is roughly double the general population. Both the number of medical illnesses and the mortality rates due to medical illness are substantially higher for patients with serious mental illness. There is a particularly high incidence of diabetes mellitus and hypertension. (Alex Young, private email)

The most recent California data show approximately 165,000 involuntary holds a year. In LA County, which accounts for 40% of those commitments, 72 hour holds last on average 48 hours; 14 day holds seven. (Gerald Minsk, private email) How competent would non-medical personnel be to recognize the related medical conditions that might become prominent once certain psychiatric symptoms subsided, what the medical risks might be?

If mental illness is a medical illness, to my mind involving non-medical personal in determining discharge criteria treats people with psychiatric disability as deserving of a lesser standard of care. People with psychiatric disability already have inadequate medical work-ups, shorter life expectancies.

If mental illness is not a medical illness, why are we locking people into hospitals?

How does an event so medically serious as to warrant a coercive health intervention become so quickly recharacterized so that criteria for recovery and discharge do not need medical oversight?

It muddles to support this inconsistency.

I think we must also consider CA legislation in its national and international context. This bill is part of a turf war between psychology and psychiatry, the first salvo towards psychologist prescribing privileges. New Mexico has passed that legislation last year. I am not yet aware of findings about the impact.

Early release frees more beds for more admissions, albeit shorter. Counties are reporting increases in hospitalization, yes shorter visits, much recidivism. I conclude that the current kind of inpatient treatment doesn’t work very well, though that may not be because of shorter stays. Managed care limits and unit census are the operative factors, not patient recovery.

My position is that anything that increases the authority of psychologists or other non-medical personnel is a bad thing. I oppose this bill. It has been suggested that it is expedient to align with the psychologists so they will align with us, for instance on the seclusion and restraint legislation.

I have three ideas for amendments:

require adequate discharge planning that includes medical follow-up and is signed off by medical personnel and an approval of the context into which the person is being released.

also allow RN’s and all others with involuntary intake authority to discharge

require a study, research that follows MD/non-MD degree status and receipt of needed medical care

I am going to continue to base my opposition to psychologist involvement in medical matters on my personal experience as well as the other arguments.

There’s a fable I’ve heard about solutions: a community nestled at the foot of a mountain was beset by infants plummeting over the cliff into the village. Villagers took turns catching the babies. The more catchers, the more babies seemed to be falling. Soon the whole village was at the foot of the cliff, catching. And a call went out to the neighboring village for more catchers. Until a villager climbed the mountain and killed the ogre throwing away the babies. And then the villagers could rest.