A few months before my mother ended up on the streets, she was admitted to the psychiatric ward at the hospital where I work as an emergency physician.
Leading up to that confession, I had barely rescued her from a manic, delusional episode when she had missed her risperidone psychiatric medication. I got a call from the police: “Your mom stole the neighbor’s dog, saying she was going to play with the neighbor’s cat.”
I once took her to the emergency room to get a prescription refill, and she became agitated and began yelling at me while she was being escorted to a psychiatric isolation ward.
“You are my daughter, not my doctor!! I am not staying here.”
Emergency room security was called. 4-point constraintMy mother is not a violent person, but she can be agitated, especially when she is off her meds. She was a victim of domestic violence and carries defensive memories of that trauma in her body.
As healthcare professionals, having to restrain patients is one of the most difficult parts of our jobs. It is one of the rare moments when we have to use force. I always fantasize that someone will invent an aerosolized antipsychotic that will put people who are a danger to themselves or others to sleep.
Knowing what would happen if my mother escalated, I walked over to her with open arms and stood there quietly. Her expression slowly softened. I hugged her as tight as I could.
From the corner of my eye, I met my colleague, Dr. Liu. “Janet, we are here to help you,” he said with his palms up and in a very friendly voice. My mother calmed down and entered the room, and we agreed to administer the medicine, which dissolved under the tongue.
As an emergency physician in Toronto, I never expected my own mother, in her late 60s, to end up spending the night on a bus bench, but in other ways it wasn’t a total surprise. Recent meta-analysesAbout 67% of people experiencing homelessness have some sort of mental illness, like my mother, who has schizoaffective disorder.
My sister and I An unconventional childhood My daughter’s illness has put us on welfare, in food banks, and in foster care after Child Protective Services found us homeless and camping in a stranger’s backyard. Against all odds, I managed to graduate from medical school, get a fellowship at Harvard, and am now a professor at the University of Toronto and the mother of two girls.
After weeks in a psychiatric ward and daily doses of antipsychotics, my mother transformed into a sunny presence frying eggs in the community kitchen. In terms of meaningful change to prevent relapse, the psychiatrist offered nothing.
My sister and I were hopeful that by admitting her to my hospital, she might finally be able to be admitted to a care facility and receive her injections.
In a family meeting with the hospital social worker and psychiatrist, my sister and I pleaded to become joint surrogate decision-makers, but we needed my mother’s consent. The team assumed that as long as my mother was taking her medication, she could make decisions. My mother admitted that she only took her medication “when she felt like it,” but it wasn’t enough to cause her any trouble in society, so she agreed to the decision. Treatment sequence.
“Your mother can walk, feed and dress herself,” the social worker said sympathetically. “We have no basis to force her to stay or care for her against her will.”
My sister and I came to an understanding that the medical system can only do so much. If you are able to perform basic functions and are not a physical danger to yourself or others, doctors can must be given the status of free willNothing in her environment had changed, so we knew continuing with the same treatment plan would only produce the same results.
Subjecting people with mental illness to treatment orders and involuntary detention is understandably highly controversial. Just as people without a formal psychiatric diagnosis are unique, so too are people with delusional disorder.
Forcibly restraining a patient is a last resort, but a necessary one, if the patient becomes violent. But with someone like my mother, who makes odd choices that may or may not harm themselves or others, it becomes a gray area. This kind of gray area occurs in all areas of medicine as well. For example, someone with a very severe drug addiction may have a hard time making choices that are in their own interest. Someone with dementia may or may not be able to carry out decisions that are in their own interest.
How do we know whether compulsory detention falls into the perfect quadrant that is in the best interest of both the patient and society, or whether it falls completely outside both ideals?
Not surprisingly, after I was released from the hospital, my mother continued to avoid regular doses of her antipsychotic medication and refused to take the injected medication. She decided to give up the house in Ontario that my sister and I had paid for. While off her medication, she secretly sub-rented the house in a one-time cash transaction and used the money to fly to Edmonton, where we grew up. Unbeknownst to us, she was then homeless.
When she went to the emergency room in Edmonton after a difficult night in a homeless shelter, the emergency room doctor called me. I tried to force her into a psychiatric unit. I was told again that she could make her own decisions. “You can’t cage a free bird,” the emergency room nurse tried to comfort me.
A few weeks later, she lost her cell phone and I lost track of her completely. A reluctant 911 operator logged her name as missing. “We don’t normally issue search calls for homeless people, but we will this time for you.”
As she sat at the kitchen table feeding her youngest child, the phone rang from an Edmonton number. She rushed to answer the phone, hoping it was her missing mother.
It was Jimmy, the security manager at Edmonton’s Mill Woods Town Centre Mall, calling to let us know that my mother had been “frequently” at the mall during the day. Jimmy managed to get her on the phone.
My mother was paranoid that she wasn’t taking her meds, and when I tried to arrange a time to visit, she was convinced that she would force me to go to the hospital again. “I won’t do it unless Jimmy brokers our visit,” my mother insisted. “I can’t be locked up!”
I couldn’t fly out until that Saturday, but Jimmy agreed to come over on his day off, and he gave me his phone number so I could call or text him anytime to check in on my mom.
My mother lost five of the cell phones I sent her during the two years she was homeless. She missed Sunday video calls with her grandchildren for two years, but when her cell phone worked, she called ten times a day just to catch a glimpse of them. When I sent her photos and video footage of my daughters, now five and eight, she commented, “It’s poetry in motion!”
Deciding whether to make someone a compulsory treatment order or to forcibly detain them may be similar to what we have to do, ethically speaking. End-of-life decisions In the ER.
When faced with making decisions for a dying loved one, the main questions we ask families are: If your family was in a position to make the decision, what would they have wanted?
Photo by Anne Aspler
I have always wanted my mother to enjoy life and have freedom. But I always ask myself, If your mother wasn’t delusional, what would she want? And the answer is typically that what she wants is a reliable place to live, a place where she can shower, a place where she can have relationships with her grandchildren. None of these things would be possible without the medication.
That being said, in those two years she had never harmed anyone, not even herself, and she was free to explore wherever she wanted, so who was I to suggest forcing her into treatment and locking her away?
In 2023, my mother was again committed to a psychiatric ward, this time at Grey Nuns Hospital in my hometown of Edmonton. A social worker persuaded her to move to a facility and begin taking Invega Sustena, an injectable antipsychotic. This time, the care team leaned toward the position my sister and I expressed. Or perhaps my free-spirited mother had finally decided she didn’t mind being caged.
It was like a miracle that I had almost given up on. Before she became homeless, as a responsible daughter who is a doctor, I asked her what she wanted at the end of her life. She said she wanted to die surrounded by nature. The following year, when she slept under a tree in the park for a night, I thought her dying wish might come true.
It all sounds so simple now: antipsychotics by injection and assisted living. But this story could have easily ended differently, with her being found of hypothermia on a cold Edmonton winter street. I still don’t know if my mom will remain stable for long, but I’m grateful every day to know where she is, sleeping in a bed with a roof over her head.
Homelessness is complex and certainly not all due to mental illness. Rising inflation and low or fixed incomes can lead to In the emergency room, we see many people who work full-time jobs and sleep in their cars or shelters. I’m not here to provide answers, but to tell a story about my powerlessness in preventing my mother from becoming homeless because of her mental illness, despite my intimate knowledge of the system.
US Federal Government Data Homelessness on the rise in most states, I hope that with our creativity and political will, we can reverse these terrible trends. People like my mother are counting on us.
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