Re: Guest post: Danger to oneself or others

1

I'm surprised that the Powers that Be resist involuntary commitments so hard.

No beds, eh?


Posted by: Sifu Tweety | Link to this comment | 07-30-14 7:55 AM
horizontal rule
2

Is this evidence that the tough-on-crime movement is entirely retributive?

Yes.


Posted by: heebie-geebie | Link to this comment | 07-30-14 7:56 AM
horizontal rule
3

2: I mean, it isn't quite, right? It makes perfect sense -- that is, it is appropriate and moral -- that our legal system isn't set up to impose penalties (whether retributive or reformatory) on people who haven't actually committed a crime. The issue is there there is no longer a parallel system of involuntary confinement to deal with people who have committed no crime, but who are dangerous and need non-reformatory help on a possibly long-term basis. That didn't happen out of a desire to punish people, it happened due to the intersection of well-meant reforms to the way mental illness is treated and ill-meant attempts to reduce the size of government without much worry about the consequences.


Posted by: Sifu Tweety | Link to this comment | 07-30-14 8:02 AM
horizontal rule
4

But the question - I thought - was "why are politicians so resistant to reforming care for mentally ill people, when they're happy to fund infinitely many beds in this other, meaner location?" Well, punishment.


Posted by: heebie-geebie | Link to this comment | 07-30-14 8:05 AM
horizontal rule
5

Prison and jail beds are usually much cheaper than mental hospital beds.


Posted by: Moby Hick | Link to this comment | 07-30-14 8:08 AM
horizontal rule
6

Plus there are issues of federalism and buck-passing. The long term mental hospitals were funded by states and the care in the community by the feds.


Posted by: Moby Hick | Link to this comment | 07-30-14 8:12 AM
horizontal rule
7

4: oh, I see. Yeah, victims of crime are much more sympathetic -- and criminals less sympathetic -- than families of seriously mentally ill people trying to keep themselves from becoming victims of crime and criminals, respectively. The latter situation is so complicated, who-to-blame-wise.


Posted by: Sifu Tweety | Link to this comment | 07-30-14 8:15 AM
horizontal rule
8

A close friend of mine is dealing with a related issue. Her nephew is schizophrenic and periodically goes off his meds for reasons nobody can fathom. Last time he did it he attacked his grandmother (my friend's mom) and she had to get a restraining order, complicated by the fact that he lives with her. Right now he's living with my friend, but if he goes off again the next option is probably living on the street until he attacks some stranger and gets sent to jail. There are apparently no resources to get him help beyond involuntary commitment for a few days to get him back on his meds, after which he's released.


Posted by: togolosh | Link to this comment | 07-30-14 8:21 AM
horizontal rule
9

In northern knifecrimea they don't resist involuntary committal that hard. I have a younger relative who is in his second stint of being detained under a treatment order.

The precipitating event this time was essentially the same as the situation in 8. He isn't on regular meds, but is generally fine, although socially isolated and occasionally depressed. He's not (apparently) schizophrenic, but has had a couple of fairly widely spaced psychotic episodes, which the psychiatrists haven't fully diagnosed. Anyway, during his last episode, he attacked the relative he lives with. Not, to the best of my knowledge in a serious way, but his affect and aspects of his behaviour were concerning enough for a treatment order to be awarded.

He's been in hospital now for around 6 months. Unfortunately, his psychiatrist appears to be an incompetent, and his previous psychiatrist was a dick. So he has no formal diagnosis,* and his treatment plan seems half-hearted -- although possibly of long-term use, if he can stick to it -- and late. It's only just got going, and the treatment order is basically expiring.

* he's been told, at various times, that he had a personality disorder, that he was suffering from psychosis brought about by cannabis use, that he has some sort of social phobia, and a number of other things. Most of which don't really fit the phenomena, which any psychiatrist who actually fucking listened to people, rather than being an arrogant box-ticking fuck, would have realised.


Posted by: Alex Salmond | Link to this comment | 07-30-14 8:31 AM
horizontal rule
10

8: Some states have tried involuntary outpatient commitment as a way of avoiding that cycle. I know it worked in pilots, but I'm not sure if it worked well in wide release. I switched fields.


Posted by: Moby Hick | Link to this comment | 07-30-14 8:33 AM
horizontal rule
11

My childhood best friend is also schizophrenic and his mom is in the same boat as these other anecdotes - he can get violent when he lives with her, he gets so frightened and paranoid and unhappy when he lives alone, and there doesn't seem to be any other solution.


Posted by: heebie-geebie | Link to this comment | 07-30-14 8:35 AM
horizontal rule
12

My experience in southern knifecrimea is similar, although on the third round of involuntary commitment my brother in law did finally get a great psychiatrist. The bar for commitment seems to be much, much lower than in the US, though - no attack was required for any of the commitments, just clear psychosis.

Now the problem is that his wife has left him and taken their two kids back to her country of origin, allegedly just for the rest of her maternity leave, although my husband and I are convinced she is not coming back. Although very smart, he is not capable of holding down a job (every attempt in the past five years has quickly devolved into a psychotic episode). He has zero savings and is ineligible for most benefits because she is employed and earns a good salary, but he has no access to it (and I'm not sure she is paid for the full leave she is taking). Also, she expects him to pay the mortgage during her absence. It's a shit show.


Posted by: Margaret Thatcher | Link to this comment | 07-30-14 8:40 AM
horizontal rule
13

I will say that this experience leaves me a bit adrift politically - I get all the civil liberties arguments against involuntary commitment, but I also don't think my brother in law would be alive now otherwise.


Posted by: | Link to this comment | 07-30-14 8:41 AM
horizontal rule
14

Yes, I'm fairly sure my younger relative would have done something fairly extreme, particularly during his first psychotic episode, when he was quite dramatically unwell.

One thing I will say, the police handled both his arrests (there were a couple) and his transport to hospital with great sensitivity and tact, and were [according to another relative who was there] very gentle and kind throughout.


Posted by: Alex Salmond | Link to this comment | 07-30-14 8:44 AM
horizontal rule
15

And to be clear - I don't judge his wife at all for leaving him. No way in hell could I sustain a marriage to this guy. But the constant back and forth about whether they are getting divorced or not (she has kicked him out and said she would divorce him four times in the last 18 months) is making things much more complicated.


Posted by: Margaret Thatcher | Link to this comment | 07-30-14 8:44 AM
horizontal rule
16

I don't think a meaningful psychiatric system is impossible to design that's not awful on the civil liberties front. You can have regular documentation on what steps are being taken to reintegrate the person into society, and not pay the caretakers poverty wages, and don't hand it over to private contractors.


Posted by: heebie-geebie | Link to this comment | 07-30-14 8:45 AM
horizontal rule
17

Perhaps they could fight forest fires.


Posted by: heebie-geebie | Link to this comment | 07-30-14 8:47 AM
horizontal rule
18

You can have regular documentation on what steps are being taken to reintegrate the person into society

What if this isn't possible?


Posted by: Sifu Tweety | Link to this comment | 07-30-14 8:49 AM
horizontal rule
19

I'm sure there's models out there on how handle permanent mental disabilities in ways that aren't exploitative - can the person handle a halfway house, etc - with the goal of giving the person a reasonable quality of life.


Posted by: heebie-geebie | Link to this comment | 07-30-14 8:52 AM
horizontal rule
20

18 is the tough problem now that the state hospitals are mostly gone. There are often very strong financial incentives and bureaucratic impetus toward attempting to reintegrate a person into society when success is very unlikely.


Posted by: Moby Hick | Link to this comment | 07-30-14 8:53 AM
horizontal rule
21

I don't really see there being a gray area with individuals that are hard to categorize, anyway.


Posted by: heebie-geebie | Link to this comment | 07-30-14 8:53 AM
horizontal rule
22

No?!


Posted by: Sifu Tweety | Link to this comment | 07-30-14 8:54 AM
horizontal rule
23

21: What? It's a huge fucking problem.


Posted by: Moby Hick | Link to this comment | 07-30-14 8:55 AM
horizontal rule
24

A profanity-level problem.


Posted by: Moby Hick | Link to this comment | 07-30-14 8:56 AM
horizontal rule
25

I mean, you either do or you don't have significant problems.


Posted by: heebie-geebie | Link to this comment | 07-30-14 8:56 AM
horizontal rule
26

A truly well-designed system would be basically infallible.


Posted by: heebie-geebie | Link to this comment | 07-30-14 8:57 AM
horizontal rule
27

No. It nearly always comes and goes depending on age, treatment, stress, and stuff nobody has figured out yet.


Posted by: Moby Hick | Link to this comment | 07-30-14 8:57 AM
horizontal rule
28

Unlikely.


Posted by: heebie-geebie | Link to this comment | 07-30-14 8:58 AM
horizontal rule
29

From Ogged, graduate-level trolling. From heebie, a visit to the argument clinic.


Posted by: Annelid Gustator | Link to this comment | 07-30-14 8:59 AM
horizontal rule
30

Mental illness is like preparing a meal - sure, a bad cook will make a mess of it, but that doesn't mean you can't have a well-written recipe.


Posted by: heebie-geebie | Link to this comment | 07-30-14 8:59 AM
horizontal rule
31

Dammit heebie, are you off your meds again?


Posted by: Sifu Tweety | Link to this comment | 07-30-14 9:00 AM
horizontal rule
32

It doesn't make me crazy to be pleased with how I trolled both Moby and Sifu in one ridiculous claim.


Posted by: heebie-geebie | Link to this comment | 07-30-14 9:02 AM
horizontal rule
33

I don't have a DSM with me so I can't check.


Posted by: Moby Hick | Link to this comment | 07-30-14 9:06 AM
horizontal rule
34

Mental illness is like preparing a meal - sure, a bad cook will make a mess of it, but that doesn't mean you can't have a well-written recipe.

Well, you see, Peter, diagnosing mental illness is a lot like making love to a beautiful woman. There's a lot of ignorant fumbling around due to lack of experience, and more often than not you get it disastrously wrong.
https://www.youtube.com/watch?v=iBw-aEixWuo


Posted by: ajay | Link to this comment | 07-30-14 9:09 AM
horizontal rule
35

I regret 32. Too soon.


Posted by: heebie-geebie | Link to this comment | 07-30-14 9:10 AM
horizontal rule
36

I'm not sure how to introduce the 3rd party payor problem into the analogy in 34.


Posted by: Moby Hick | Link to this comment | 07-30-14 9:11 AM
horizontal rule
37

If you'd been slower off the mark with 32 you would have sucked me in as well.


Posted by: LizardBreath | Link to this comment | 07-30-14 9:19 AM
horizontal rule
38

Sane families are all alike.


Posted by: Minivet | Link to this comment | 07-30-14 10:05 AM
horizontal rule
39

I am kicking myself.


Posted by: heebie-geebie | Link to this comment | 07-30-14 10:11 AM
horizontal rule
40

Sanely, of course.


Posted by: heebie-geebie | Link to this comment | 07-30-14 10:11 AM
horizontal rule
41

This topic sort of makes me wonder how Psychiatric Advance Directives have worked out.


Posted by: Moby Hick | Link to this comment | 07-30-14 10:14 AM
horizontal rule
42

My once upon a time neighbors across the street have just gotten their now severely brain damaged, druggie, easily triggered to violence, ex-marine back home 'cause there are no other options available to them. They're worried, my daughter is worried, and there is nothing good anticipated. "The system" can go fuck itself.


Posted by: biohazard | Link to this comment | 07-30-14 10:37 AM
horizontal rule
43

Brain damage is probably the worst.


Posted by: Moby Hick | Link to this comment | 07-30-14 10:39 AM
horizontal rule
44

"Probably?" Just consult the official ranking.


Posted by: heebie-geebie | Link to this comment | 07-30-14 10:40 AM
horizontal rule
45

At least the family in the OP is sane and identifies the real issue. Back in So Cal it's "Freeway incident raises questions on how police interact with public". Or, maybe there should be some intervention before crazy lady living under the overpass decides to wander into freeway traffic and then fight the highway patrol guy who tries to stop her. Fortunately everyone will stand around wringing their hands over how someone got punched and the family and their lawyer will tell us all how they're concerned she's being involuntarily kept in the hospital on a psychiatric hold.


Posted by: gswift | Link to this comment | 07-30-14 11:03 AM
horizontal rule
46

11: Group home?

There's been a cut in MA even long after the Medicaid Rehab stuff came in. 2 hospitals were merged and shrunk in a new hospital. Many were shut in the 90's

Even for short term stays which technically count as "being in the community" there are not enough beds, and most of them are for-profit stand-alone hospitals. If you are taken to the hospital and a hold or even a "voluntary" hospitalization is desired, you have to get evaluated by a mobile team which then proceeds to do a bed search.*

*This can be avoided if you have $40,000/ week in cash to pay for luxury care at McLean's Pavilion.


6: The money thing is funny. I always thought that you couldn't bill the Feds, but I know that at at least one State hospital Medicare is routinely billed for some of the services (and then the patients get billed, though no collections are pursued).

As best I can figure it out we have 1.5 exclusively mental hospitals, and the other two are Department of Public Health Hospitals which have more beds for chronic medical conditions than for mental health issues. I think that that means that makes them not primarily mental hospitals, and they get a pass from Medicare.

It also means that they won't increase funding for DMH hospitals unless they also increase funding for DPH beds.



Posted by: Bostoniangirl | Link to this comment | 07-30-14 11:45 AM
horizontal rule
47

The UK has a higher bar for commitment, though people can be forced to be evaluated and then often agree, and if they are impaired enough their guardian can agree.

The lack of beds is a big issue.

The UK is better about avoiding the use of restraints.


Posted by: Bostoniangirl | Link to this comment | 07-30-14 11:47 AM
horizontal rule
48

My information on how funding happens is a decade out of date and I'm sure yours isn't. I was thinking back to the original push to CMHCs, which was still an actively studied thing back when I started.


Posted by: Moby Hick | Link to this comment | 07-30-14 11:48 AM
horizontal rule
49

16 and 18: Sometimes it's not.

Most of this is contracted out now. The pay at the vendors/ agencies is lower than the pay at the State used to be or is for the few remaining programs. State workers are represented by a union.

Although, to be honest, the mental health workers at the state are poorly paid and not treated with much respect. For example, they don't even get e-mail addresses.

The agencies aren't raking in a ton of money. The CEO might be paid well, but even Senior managers (outside of HR) are not well paid, and they are not for-profits.


Posted by: Bostoniangirl | Link to this comment | 07-30-14 11:53 AM
horizontal rule
50

41: I think they would work out if you were someone like Kay Redfield Jamison who could easily get into Hopkins, because she's famous and on the medical faculty there.

Nowadays, if you notice that things are getting bad and you think you need to be in the hospital, they will divert you to an intensive outpatient program.

In other words, by the time the medical establishment thinks you need to be admitted, a patient's wishes are irrelevant.


Posted by: Bostoniangirl | Link to this comment | 07-30-14 11:55 AM
horizontal rule
51

48: Yup, and that was what I always thought. Until I found out that 2 of the 3 state hospitals *do* bill.


Posted by: Bostoniangirl | Link to this comment | 07-30-14 11:57 AM
horizontal rule
52

I have been involuntarily committed three times; the last two were consecutive. The first time, I was denied an appeal my lawyer was enthusiastic about. The second time, the judge (quite illegally) announced in my presence I was the subject of a National Security Letter - I don't know why. The third time I didn't even get an initial hearing. So I'd wager there is quite a bit of WTF to go around in most cases, even if you grant (as I will) that institutionalization is better than homelessness and mental cells in jail (very close to solitary), suicide, drug abuse - the live options in contemporary society for severely mentally ill people. Beyond that, I'll grant that Adam Lanzas are a sort of 'killer app' for a non-libertarian approach to acute mental illness.

What I would sincerely request is that the damn med-worship which characterized the late 90s, as in Placebo, not be proffered as a reason for this. Anti-psychotics are, as originally advertised, "major tranquilizers" - they have salutary behavioral effects on messed-up people. However, medical researchers have given up on the idea jerry-rigged pills should have wonderful effects on distorted cognition, and now incline toward thinking anti-psychotics basically vaporize brain mass, particularly in the cortex. As already mentioned this is not a reason for tolerating mass murder - but could you stop fucking with people in an insoluble, extremely dysphoric downward spiral?


Posted by: Bob Roberts | Link to this comment | 07-31-14 3:55 PM
horizontal rule