Heller’s Asylum

Psychiatry and the ER

Every physician knows the look. A police officer at triage, a patient in paper scrubs, a pink Writ of Detention. It is a ritual that repeats daily in emergency departments across the country. The patient has been deemed unsafe, unmanageable, or simply intolerable to someone else, and so they are sent to the one place that cannot say no. The ER has become the asylum of last resort, but unlike the asylums it replaced, it was never built to heal the mind.

In theory, a patient in psychiatric crisis is supposed to receive evaluation and treatment. In practice, I can do neither. I am not a psychiatrist. I cannot prescribe most psychiatric medications safely without follow-up. I have no long-term relationship; I cannot offer continuity or psychotherapy. I must operate under the assumption that I will never see this patient again, though many do return in the same condition. I am asked to judge risk, not to restore sanity. I determine whether the patient may go home or must be confined, and I do so on the basis of a few minutes of conversation, an absence of context, and an abundance of liability.

Patients arrive expecting expertise. They imagine that “psych eval” implies some technical process, perhaps testing, perhaps the insight of specialists. What they receive is a checklist. Are you hearing voices? Do you want to harm yourself or anyone else? Have you made a plan to do it? Few are the questions that determine whether a person will sleep tonight in their own bed or behind a locked door. I am well aware of the absurdity. Yet this is what psychiatry has become in the age of protocol: an algorithm for human despair.

Psychiatric hospitals rarely evaluate patients themselves before admission. They rely on my clinical description relayed by phone call. I may think someone needs admission, but that decision belongs to the psychiatrist on the other end of the line, and they can decline. Many do, especially for patients who are violent, drug-intoxicated, or otherwise complicated. Those patients remain in the ER for hours, sometimes days, waiting for an inpatient bed that may never materialize. They are too dangerous for one institution, too sick for another, and too unstable for the street. The ER becomes their holding cell, and I, their reluctant jailer.

It is fashionable to speak of a “mental health crisis.” What is less often said is that the crisis is administrative, not medical. Psychiatry has fragmented into a bureaucracy of risk management and reimbursement, while society has dismantled every other institution capable of dealing with madness. The asylum closed, the church retreated, the family disintegrated, and the police are told to deliver the broken remnants to the ER. The doctor becomes the inheritor of everyone else’s failure.

Defensive medicine infects psychiatry just as it infects every other corner of care. The decision to admit or discharge has little to do with whether hospitalization will help and everything to do with risk. The incentives are backwards. We hospitalize not to heal but to shield ourselves from blame. Inpatient psychiatry rarely changes the course of these patients’ lives. Most have cycled through the same wards countless times, emerging no better and often worse; they are more medicated, more dependent, more estranged from the world. The decision to admit is not an act of hope but of surrender, a way to offload liability onto someone else. Meanwhile, the ones who genuinely want help are turned away because they do not meet criteria. In the ER, psychiatry is not about who can be healed, but who can be held.

In the absence of psychiatrists, emergency physicians have become their proxies. We perform psychiatric pseudo-evaluations without the authority or the tools to treat. We make moral and medical judgments with no long-term knowledge of the patient, and then hand them back to a world that will do nothing for them. There is no continuity, no follow-up, no healing relationship. Medicine has been reduced to a series of isolated transactions, each one clinically defensible, and none of them truly therapeutic.

The deeper absurdity is that psychiatry itself no longer believes in sanity. Where medicine once sought to restore order to the mind, it now seeks to affirm delusion. Nowhere is this clearer than in the cultural capitulation to transgender ideology, where the doctor’s role has been reduced to validating the patient’s fantasy and mutilating the body to fit it. A profession once committed to curing psychosis now demands that its practitioners participate in it. The same logic underlies much of modern psychiatry: that affirmation is therapy, that denial of reality is kindness, and that suffering can be cured by redefinition.

To practice emergency medicine is to stand in the ruins of psychiatry. The ER was never meant to absorb the totality of human despair, but it has been made to. It is the only institution that remains open when every other door has closed. Police drop off the disturbed and the violent, and the state hides its failures behind our locked triage doors. We are asked to solve problems that are moral, spiritual, and social, yet we are armed only with sedatives, restraints, and paperwork.

Most of us entered the field believing we could help. We thought that our skill and empathy could make a difference. But over time, the pattern wears us down. We realize that we are not rescuing anyone. We are processing them. The patients return unchanged, the paperwork grows longer, and the illusion of doing good becomes harder to sustain. What remains is the performance of care without the substance of it, a ritual meant to reassure the system that something is being done.

The result is a kind of moral injury, a wound of the conscience rather than the body. To be an emergency physician is to be made responsible for unfixable problems and to pretend each day to believe in solutions we know are false.

“Orr would be crazy to fly more missions and sane if he didn’t, but if he was sane he had to fly them. If he flew them he was crazy and didn’t have to; but if he didn’t want to he was sane and had to.”

— Joseph Heller, Catch-22

The more clearly you see the madness of the system, the more insane you must become to keep working within it. That is why so many of us, over time, become patients of the very system we serve.¹ We are asked to shoulder impossible burdens, to fix what cannot be fixed, and to act in contradiction to what we know is true. Eventually that contradiction corrodes the soul. The madness of the system becomes our own.

1. American Medical Association. Preventing physician suicide. American Medical Association website. Published 2024. Accessed October 4, 2025. https://www.ama-assn.org/practice-management/physician-health/preventing-physician-suicide

Duarte D, El-Hagrassy MM, Couto TC, Gurgel W, Fregni F, Correa H. Male and female physician suicidality: a systematic review and meta-analysis. Gen Hosp Psychiatry. 2020;63:51-63. doi:10.1016/j.genhosppsych.2019.12.011. Accessed October 4, 2025. https://pmc.ncbi.nlm.nih.gov/articles/PMC6907772