It is good to seek admission to the psychiatric ward (Psych Ward) of a suitable hospital if you are in danger of harming yourself or others, for containment until you are stable enough to leave. Sometimes we do not have the insight to make that decision and may be brought into hospital against our will, or if initially in hospital voluntarily, if we lack the insight to see the need to stay for the sake of safety, we may be made involuntary. In the bad old days, this could and was used against people who should not have been kept against their wills. This abuse of the system is now extremely hard to to. Psych Ward is about containment, not about healing.

Psych Ward is About Containment, not Healing

Many people I talk to who have been admitted to the Psychiatric Ward of a Hospital (Psych Ward) complain that they didn’t get better while there. I think their expectation is that they would get a good diagnosis, good medication, good group therapy, good individual therapy and be able to leave as a healed contributing member of society. That is not the purpose of Psych Ward. That is the what mental health therapy in the community is about.

People who go to Psych Ward have exceeded the care ability of the mental health services in the community (home). Most commonly, a person admits themselves to Psych Ward when they feel like they are unable to keep themself safe in some significant way, or perhaps keep others safe from themselves. This can include significant deliberate self-harm that could be life threatening or permanent, suicide, or risk of harming another person. Even so, it is hard to be admitted. Most psychiatric units are full or close to full. Frequently the assessing team need to work out not only if you fit the criteria for admission, but if your situation is worse than the least risky person currently in the ward. Mostly this is due to poor funding for mental health, especially for hospitals.

You may not have the insight to recognise that your actions are unsafe. We’ll delve into this a bit later. The point for this is, someone else has determined that you are a risk to yourself or someone else, and so you have been admitted on your behalf.

The goal of the Psych Ward is to get you safe enough that you can be discharged. Sometimes, that means a better diagnosis and better medication. Sometimes that means filling in some necessary blanks in your knowledge of how to manage so that you are able to be safer or better self-managed. Once you are safe enough to discharge, then you can go on to mental health services that aren’t part of the ward. While they are helping you reach that target, they will do their best to contain the risk portion of why you couldn’t be helped in the community.

That is, the goal of Psych Ward is containment until you are safe, then release – it isn’t to heal you.

Psych Ward is Generally Neurodivergent Unfriendly

Autism, ADHD and BPD are not part of the general qualifications for psychologists, social workers or psychiatrists. Most people who qualify with these degrees and become therapist certified did not learn about these conditions. Most of what they know are the pop-psych stereotypes. What that means is, unless you look much like the most stereotypical presentation of the relevant condition, they will most likely misdiagnose you and thus their treatment plans will be wrong and likely ill fitting; and even if they do recognise the condition that you have (or you have been pre-diagnosed), they still won’t know how to give a positive treatment plan for your condition.

Personally, this is a tragedy. Most of the people in Psych Ward are neurodivergent, with many Autistic and ADHD people who haven’t been property diagnosed, or aren’t being treated in a friendly way. Most people who are in Psych Ward for containment and are Autistic and or ADHD will likely be given a diagnosis of BPD. In our BPD page, we make the case that this is not a good diagnosis for anyone, however the particular pattern of behaviour that led to this diagnosis can be good to note.

BPD is considered anathema to Psych Ward, and should be you be diagnosed with it, they’ll implement the unwritten policy of “patch em up, get em out”. While that sounds callous, it is actually the best thing they can do for both you and them. If you are diagnosed with BPD, the longer you stay in Psych Ward, the worse you’ll get, and the higher the risk of harm.

Psych Ward means Antipsychotics

The most common medication given in Psych Ward is antipsychotics. There is a good systemic reason for this.

• Antipsychotics have the benefit of nullifying the more common mind altering recreational drugs that cause psychotic presentations,
• Effectively treats half of the people who are schizophrenic, and
• Pacifies most of the people who are agitated with its sedative qualities.

This pacifying aspect makes sense when you realise that most people admitted to Psych Ward are agitated and the goal of Psych Ward is to contain you until you are safe to discharge. People who are at risk become far less so once they have been given an antipsychotic, and the risk to health is very low for short term use, even if this medication is not ideal for your diagnosis.

Antipsychotic medication is not compatible with most people diagnosed with ADHD and Autism; and minimally useful for BPD, Anxiety and Depression. As noted above (Psych Ward is Generally Neurodivergent Unfriendly), Psych Ward often doesn’t recognise that your actual condition is Autism or ADHD, and often misdiagnoses people with this neurology for conditions like BPD, Bipolar or Schizophrenia.

ADHD is a common hereditary congenital neurological condition (around 5-10% of the population, it runs in families, you are born with it, it is a difference in neurology) that leads to problems using Dopamine in the prefrontal cortex (the bit of brain just behind your forehead). This can be a problem creating sufficient Dopamine to use to think with, or getting enough Dopamine in the synapses to register a synapse signal (simplistically, insufficient to flip the communication switch). The key aspect of this is that sufficient dopamine molecules need to fill the synaptic gap to key into the Dopamine Receptors to pass the signal from one neuron to the next. There are 5 types of Dopamine Receptor, and each will manage a different aspect of higher order executive thinking. Antipsychotic medications works by blocking Dopamine Receptors in the brain, which make ADHD symptoms worse and effectively block ADHD medication from working.

Atypical Antipsychotics work the same way as typical antipsychotics, but won’t block all 5 of the Dopamine Receptors. This can allow targeting the Dopamine Receptor that is connected to the faulty brain mechanism that is causing odd behaviour in someone with schizophrenia (mostly the D2 neurotransmitter), without knocking out the other executive functions that the other Dopamine Receptors manage. For ADHDers, this it is often better to take an atypical antipsychotic than a typical one, but even then, it is hard to get your brain working again when your ADHD symptoms have been exacerbated.

The more up to date medical science indicates that the overlap between Autism and ADHD is around between 22% to 83% (Aspect “Autism and ADHD (AuDHD) Fact Sheet”) (ASD and ADHD Comorbidity: What Are We Talking About?), and I argue that it is closer to 100%. What this means at the least is that many Autistic people won’t benefit from being prescribed antipsychotic medication in the long term.

As we will see, part of being able to be discharged is demonstrating competence and safety. This is very hard to do when your executive function has been compromised.

Involuntary Psych Ward

A person who is committed on the Mental Health Act to involuntary psychiatric care, is referred to as someone who has been Sectioned or Formed.

The rules around Involuntary Psychiatric Care in Western Australia are from the Mental Health Act 2014 (MH Act). If you are not in Western Australia, your rules will be specifically different, but shouldn’t be too different to this.

Involuntary, for when you aren’t rational and or safe

The specifical legal definitions for how this is done is intricate, so first we will cover the TLDR brief summary, then the nitty gritty of how and what according to the WA Mental Health Act 2014.

TLDR Why and How

If your cognitive process is compromised, you will struggle to understand what is going on. You may think you know, but you don’t, and for your own sake, you need to be contained. If you don’t know you need to be contained, someone will make that decision for you. You can be referred for involuntary psychiatric care by an authorised mental health practitioner.

We (people) make decisions on four key aspects:

• How we feel about something
• Insight into the consequence of our, and thus why events around us may be due to ourselves
• Judgement about what is good for ourselves and our community
• Sufficient memory to be able to review the past, recognise the present and recall our decisions and reasoning later

Once we make a decision, we then enact that via our actions. How we do those actions is a large part of our behaviours. If we lose track of why we are doing something, or our values for insight and judgement become distorted, are we just don’t remember what we decided, our behaviours become erratic.

You will primarily be assessed in person, but if that isn’t possible, you may be assessed by video, by a psychiatrist. If you are deemed needing involuntary treatment, then you will be sections. If you are in a metropolitan area, that has a limit of 3 days, while if you are in a rural area, this can be extended to up to 6 days.

After this time, you will either be released automatically back to voluntary care or home, or if assessed, your involuntary treatment be granted a continuation of up to 3 months for adults, or 28 days for youth. You may be released earlier than this if you are assessed to be back to your right mind and no longer a risk or at risk.

The assessment is trying to determine a few key things:

1. There is a significant risk to health or safety of the person or to another, due to a mental illness,
2. The person of concern does not demonstrate the capacity required to make their own treatment decisions,
3. That this can’t be managed in the community under the usual means (GP, therapist).

Once the psychiatrist has confirmed this, they may make an order for the person to be treated involuntarily in a ward (authorised involuntary psychiatric ward), or receive involuntary treatment in the community (community treatment order).

Important Technical Specifics

A person can be deemed incapable of making their own treatment decisions due to mental illness and due to a risk of harm or safety, be required to received involuntary treatment.

1. Authorised Medical Practitioner refers for assessment
   • If you do not present as a person in risk and also incapable of making wise medical treatment decisions for yourself, they will get in trouble for referring you.
   • You can be held for up to 3 days in metro, or 6 days rural, for assessment.
   • If no assessment is performed, you will be automatically released.
   • An assessment must be done by a psychiatrist.
2. Psychiatrist’s assessment:
   • If the psychiatrist deems that you are incapable of making valid health treatment decisions and you are at risk, they can order:
     • Involuntary treatment in a ward registered for involuntary care,
     • Involuntary treatment in the community by the Community Team.
   • Or released as not deemed capable / not at risk
3. You can be made involuntary for up to:
   • Adult: 3 months.
   • Youth: 28 days.
   • You may be released earlier if you are assessed by a psychiatrist to be capable of making your own treatment choices (recovered), or you are no longer at risk (within reason) if discharged.
4. Follow up assessment (if not released):
   • If no assessment is performed, you are automatically released.
   • An assessment may continue your treatment order for another time as per (3) above.
     • There is no limit to total length of stay, so long as a psychiatrist continues to deem that you are incapable of making medical decisions and continue to be at risk.

That means, to be released, you need to show that you are:

• Stable mood,
  • That is, your mood is stable and managed, ie calm.
• Cognitive:
  • Understanding relevant medical health information,
  • Making reasoned / rational decisions about that information.
• No longer at risk
  • No Risk to self:
    • Not likely to self harm,
    • Not planning to end your life,
    • Have plans to see a therapist,
      • Such as an appointment within a week of discharge if you have a current therapist,
      • A referral to a clinic and a therapist who can see you soon.
    • Have other near future plans,
    • Caring about your appearance.
  • Risk to others:
    • While you may have some strong feelings about someone (such as anger):
      • You do not plan to harm them,
      • You have a non-violent process to enact to manage the conflict.
    • Or you don’t have any concerning plans or feelings towards others:

Defining Authorised Medical Practitioners

The MH Act, requires the referral to be made by an Authorised Medical Practitioner in Section 26, but doesn’t define who else beyond GP and Psychiatrists can make that referral.

Defining “not capable” and “risk”

A Psychiatrist will determine, via Section 25, if a person meets the criteria for being incapable of making treatment decision for themself, and is at risk.

1. Psych Ward: The person needs care for mental health reasons and the person doesn’t demonstrate the capacity to make treatment decisions about themself, and this can’t be done in the community or in a less restrictive way.
2. Community Treatment: Effectively the same as above, but can be managed in the community by a treating team.
3. Within the rules of the MH Act.

Defining “Capacity to make own treatment decisions”

By default, all adult people are considered to have the capacity to make their own treatment decisions, unless a circumstance has occurred that leads the person to have a legal guardian (beyond the scope of this document). A person may acquire a temporary or long term incapacity to make treatment decisions about themself due to mental illness. A psychiatrist needs to make this determination if the person is referred by an authorised Medical Practitioner. The psychiatrist will use this guide to determine if they meet Section 18, “Determining capacity to make treatment decision“. The person will determine they have capacity to make their own treatment decisions if they show the required understanding about the treatment (as per Section 19):

• that has been communicated to them,
• the matters involved,
• the effect the treatment should have
• can weigh up the factors above, and
• can communicate their reasoned decisions about the treatment.

Defining how Assessment must be conducted

A psychiatrist must assess a person who is being considered to not have capacity to make their own treatment plans based on the guidelines for assessment (Section 48).

1. The assessment must be conducted in the least restrictive way that is safe.
2. Preferably in person, or
3. Audio + video if not practical to do so
4. [The “location” of the assessment is where the person being considered is physically, not where the assessor is, eg if via video.]

If the person being assessed is of Aboriginal or Torres Strait Islander descent, Section 50 requires that the assessment is done in collaboration with either an Aboriginal or Torres Strait Islander mental health worker, or “significant members of the person’s community, including elders and traditional healers.”

The Result of an Assessment

Once assessed, the examining psychiatrist must either order:

• The Beginning of or Continuation of Involuntary Treatment:
  • the patient be admitted for treatment in a ward as per Section 87 (a) and (b)
    • which includes extending the stay for another amount of time (up to 3 months for adults, 28 days for youth – Section 89 (3) )
  • the patient to be treated in the community
    • which includes extending the stay for another amount of time (up to 3 months for adults, 28 days for youth – Section 89 (3) )
• The End to Involuntary Treatment.

Length of Detention / Involuntary Treatment

A person who is referred for assessment for receiving Involuntary Treatment can be detained for up to 3 days. If the person is in a rural area, they might have that continued to 6 days if an assessment cannot be made within 3 days (Section 28).

Once a person is assessed is not having the capacity to make their own treatment decisions and is at risk, they may be detained for up to:

• Adults: 3 months
• Youth: 28 days

After this time, they must be assessed again according to the requirements of Section 25, and determined to still be unable to make their own treatment decisions and still be at risk to continue for another term of 3 months or 28 days.

Your Rights

Section 52 (3), The person in charge of the authorised hospital must ensure that the person has the opportunity and the means to contact any carer, close family member or other personal support person of the person, a health professional who is currently providing the person with treatment and the Chief Mental Health Advocate — (a) (b) as soon as practicable after the person is received into the authorised hospital; and at all reasonable times while the person is detained there under subsection (1)(b).

This is Necessarily a Summary

The entire Mental Health Act 2014 is quite long and intricate. I have gathered here the essential nutshell for the typical case. The Act has lots of specifics about how each variant of the typical pathway should be managed. While the policies of the hospital and medical practice cannot go against the Mental Health Act 2014, their specific policies and procedures may add to the process.

References

Mental Health Act 2014, https://www.legislation.wa.gov.au/legislation/statutes.nsf/RedirectURL?OpenAgent&query=mrdoc_29652.pdf

Clinician’s Guide to the Mental Health Act 1996, https://www.health.wa.gov.au/~/media/Files/Corporate/general%20documents/Mental%20health/PDF/Clinicians_Guide_to_MHA.ash