Executive Order 14321

Trump did the right thing for the wrong reason. During the 60s and 70s there were too many people placed involuntarily in psychiatric hospitals for the wrong reasons. Family members could commit other family members in hospital treatment for little or no reasons. This was captured by the movie, One Flew Over the Cukoo’s Nest, staring Jack Nicholson. The response to this was a movement based in patient’s rights which led to a revision of the standard questions for admission to a psychiatric hospital called Executive Order 14321.

President Trump issued this order of widening the reasons that people could be hospitalized to get homeless people off the streets. Remember the axiom that I taught my ethics students that everything in life works both ways. This bill was addressed to lump all homeless people together as having mental health issues when that was hardly the case, but it did move us away from considering putting people in a psychiatric facility for other reasons that did not have to conform to the “no” answer of “Did they hurt you? Did they hurt themselves? No.”

A friend and colleague of mine, Dominic Sisti, Senior Fellow in the Department of Medical Ethics and Health Policy of Behavioral Health Care at Penn, spoke against Executive Order 14321. I first met Dom when I took 24 EA faculty members to the Penn Center for Bioethics one summer to learn about bioethical decision making. What do you do with answers to a dilemma are clearly right or wrong? That is different when choices can both be right or both be wrong. The latter of the three decisions make choice more difficult.

I am hoping that Executive Order 14321 can lead to getting help for people who do need care in a psychiatric hospital that admission is broader than “Has the person hurt themselves or have, they hurt others.” So, the Executive Order has two sides to it. It can be abused as was seen in the 60s and 70s, and it can fail to make sure that people who need to be in psychiatric hospital can get proper care if their situation doesn’t apply to those two questions mentioned above.

These two questions have created a nightmare for me to get people who very much need to be in an inpatient facility gain admission. In addition, insurance coverage is based on the 30 days limit that should be able to help any mental health issue which is very outdated.

I will tell you three anecdotes, one that I still remember vividly that occurred late one Friday afternoon when I was counseling someone at a mental health center that I founded with others near Chester, Pennsylvania to serve the people in that city and the surrounding area.

I was counseling a woman who was part of the Chester Mob. She always came to our sessions dressed in a black cape which covered her arms and hands. We connected well during the early sessions, but about four sessions into the counseling she sat across from me, stared at me and didn’t say a word. If you think scary movies are difficult to watch, try seeing someone descend into madness right in front of you. The reality is that a person descending into madness is more afraid than you are. I remained seated so that I wouldn’t threaten her by my size as she circled me with her hands under the cape. My question was to myself? What does she have under that cape? She finally simply left. But there was another problem. In the intake I learned that she had two small children at home. When I called the nearest psychiatric hospital, they asked me those two questions. My answer was, “No!” Their response was, “Sorry we can’t admit her. But what about the children. Still, “no.”

I called the police and told them her address and indicated that if they stood in front of her home, she would surely attack them and they could arrest her, get her the help that she needed, and the children could be put with the local children’s social services. That is exactly what happened.

Two incidents happened at the school chapel on the Merion Campus. This was before Columbine, so security was not so tight. There was a code that I could call our plant operations people if someone was on campus who shouldn’t be. I was off campus at a meeting. When I returned to campus, faculty said, “Jim, I am sorry about what happened to your office.” When I got there, the office was in complete shambles as the woman went berserk when a large policeman entered the office to intervene. Remember they are more afraid of you. He scared the woman by his size. She was taken to the nearest psychiatric facility and got the help she needed because of her violent attack on the police. She got the care she needed. Of course, the students including one of my sons were surrounding the chapel. He was saying, “My dad is in there! I am going in?” He didn’t know was off campus at a meeting.

But the second incident is why we need Executive Order 14321. During a Middle School Chapel Service, the Assistant Head of Middle School came back to my office to indicate that there was someone in the chapel who was lying down on one of the back pews and wouldn’t get up and wouldn’t leave.

I indicated to this leader to get everyone out of the chapel and call the police and plant operations, and I would see what I could do. When I went out and talked with him, he finally got up. I didn’t have to worry about being smaller than him as he towered over me, and I am 6’1”. I tried everything that I knew to do from my training. Nothing worked! It was him and me alone in the chapel. Then I received a tap from behind on my shoulder. I turned, and it was a member of my Religion Department, Kris Ryan, an All-Ivy member of Penn’s football team. I will never forget his words, “Rev, I got your back.” Shortly the police came. But I learned later that they took the unwanted guest to an avenue a short distance away and I learned that they couldn’t get permission for him to go to the nearby psychiatric hospital. It was those two questions that stood in the way. “Has he hurt you? Has he hurt himself?”

I have just one question. Where was Executive Order 14321 when I needed it?