Psychology, the law, and being committed

[flight]

An exgirlfriend of mine found herself in an odd situation a while before I new her. She had recently started a graduate psychology program and knew few people in the area. She purchased a mini-barbecue unit in order to grill some fish.

She was never one of those people who are terribly aware of their surroundings and didn't know that grilling indoors was a bad idea. She grills up the filets and blows out the flames, failing to realize that the coals were still hot (or that that is how you are supposed to cook things on a grill anyway).

In a half hour or so she starts to feel very sick. Huge headache, vomiting, what have you. She begins to realize it is something in her apartment, so staggers outside in the freezing cold in just a robe with her cell phone. The fire company comes and vents out her place and takes her to the hospital where they find she came pretty close to dying.

All better you think? Lesson learned? Not quite. She has to appear before a judge because they think she was trying to kill herself and they don't want to let her go. She says she did not know enough about carbon monoxide or how it is produced to have known that that would even be a method of suicide. She explained that she had not severed ties with anyone, tidied up her business, or done any of the things one normally does before suicide.

Apparently this was not enough, though, as they committed her anyway. When you are committed by a judge they can pretty much keep you as long as they want until they determine it is safe for you to leave. You have no control. Oddly the only way she was able to get out (after about a week) was by telling them what they wanted to hear, that she must have "subconsciously" wanted to kill herself and that she would try to work on things. This is similar to very famous psychological experiment (I don't have the site but I am sure anyone in psychology her could provided it) wherein perrfectly sane people were committed to see how the system handled them. Though they acted perfectly sane, their sane behavior was construed as indicators that reinforced the idea they were insane. No one believes a sane person in a nut house.

So, this leaves me with the point. Our government (laws may vary by state) has the right to imprison us without a jury trial for an indefinite period of time when we have done no wrong. I understand in some cased this may be necessary, but for those who are abused by it there is no recourse. Telling everyone you are sane just reinforces their belief that you are not. Is this right? Do we even have the right to protect people from themselves? Isn't his opening the door to the ideal way to remove political dissidents (though I do not believe that has yet been done)?

[greck]

Could it be that your friend told you this version of the story to save some face?

I've been working in mental health for 15 years now. If it's one thing I've learned, it's that nobody wants to pay for an inpatient stay if it isn't absolutely necessary. We're talking about at least $600 a day.
This has become more the case over the last 7-8 years too. When did this happen?

But let's assume that your version of the story is acurate and there was a miscarriage of our laws.
I find it really hard to believe that she was hospitalized without giving the evaluator some indication that she was a danger to herself, or a danger to others.
I gotta say, I'm not real big on the existence of "common sense" but sheesh! I think she might have been an acute danger to the community if she didn't have the sense not to have an open fire in her house.
A grad student not understanding why fireplaces have chimneys? Come on!

And she didn't have to lie. All she had to do was make it clear to the staff at the hospital (treatment center, whatever) that she wasn't suicidal, had no ideation, intent or plan.

Are you sure this story wasn't made up?
Did it happen like in the 70's or earlier?

Laws to protect people from making the permanent decision to kill themselves when in the throes of mental illness are sound, they have checks, and are a good idea.

At absolute worst, there was a mistake made, but I doubt it.

[Hentor the Barbarian]

I agree with greck. It sounds pretty far fetched. Generally, mental health professionals have no desire to hospitalize people any longer than necessary (necessary meaning provide treatment and avoid being sued). I have never, ever heard of people being hospitalized for a speculated subconscious desire to hurt themselves. I suppose it varies by state, but it is also not true that you may be involuntarily committed for an indefinite stay, at least not without re-review. In my state, initial involuntary treatment is 48 hours, I believe. I think after that it is 30 days. I would have to double check on that first though.

[TVAA]

Medical professionals in "college areas" often have to deal with lots of drug/alcohol problems, hidden or disguised eating disorders, and suicide attempts.

Since they so often are required to apply hammers, everything begins looking like a nail.

In college, I once went several days straight without sleep and became delirious. The doctors at the emergency room where I was taken wouldn't believe that I wasn't on drugs. They actually drew blood four times to repeat the tests that kept coming back negative; when they couldn't find anything, they decided that I had meningitis and gave me a spinal tap to check.

When I finally came to (the combination of sedatives they administered to "relax" me and exhaustion took nearly two days to wear off), they questioned me dilligently about what drugs I had supposedly taken and insisted that they would soon find out anyway when the toxicity screens came back, so I might as well tell them. (I'm fairly certain the more sophisticated tests had already come back and been negative.)

After I said that I thought the combination of sleeplessness (I normally need quite a lot) and dehydration would more than account for my condition, they said "All right, if that's the story you're happy with." Then they wanted to keep me for several more days for observation and an MRI -- and when I asked why they thought these things would be necessary, they replied that they thought they would be a good idea (well, duh).

As I insisted on leaving, they insisted on giving me a prescription of antipsychotics "to help me sleep". As far as I was aware (and I've never found any evidence to indicate I'm correct) even the atypical antipsychotics aren't prescribed as sleep aids. What was even more amusing was that, as soon as any nurse entered the room and glanced at the informational sheets left by the doctors, they exclaimed "they're just to help you sleep". Riiight.

In summation: don't assume that doctors are competent, and don't assume that there must have been clear evidence that this student was trying to harm herself. There are enough overzealous and well-intentioned doctors that the OP's story could well have happened.

[lee]

Ok, they commit her because they say she was suicidal. What is their incentive to release her if she doesn't back them up? If the says the right thing they look good. If she refuses, everyday you stay in one of those places you credibility goes down. People assume you would not be in there unless you have a real problem. Denying the problem is evidence of its severity. If they release her and she was never suicidal, it looks bad for them.

The problem is worse in college towns. Some colleges are so paranoid about suicide they get fellow students to spy on others for the signs. The shrinks in these towns need to be quick to see that those the college questions are suicidal if they want to do a good business. Also, once you admit you are suicidal, the college is happy because they can use that to throw you out if they feel like it. They probably won't unless you rock the boat, but they like having the option and shrinks seem happy to give it to them.

[KellyM]

It's perfectly credible that someone might unwittingly be grilling indoors without having "suicidal tendencies". There are lots of stories of people who grill indoors floating around (here's a "police beat" report from Kalamazoo, Michigan of such an incident involving college students) and most of them amount to "wow, I did not know that".

Did anyone check to see if the doctor involved had an ownership interest in the property? Back when I lived in a college town, most doctors had shares in the REITs that owned most of the student apartments. I've known doctors scummy enough to commit someone in order to protect their own investments or to punish someone who hurt them.

[auliya]

Originally posted by flight

This is similar to very famous psychological experiment (I don't have the site but I am sure anyone in psychology her could provided it) wherein perrfectly sane people were committed to see how the system handled them. Though they acted perfectly sane, their sane behavior was construed as indicators that reinforced the idea they were insane. No one believes a sane person in a nut house.

This was Rosenhan's 1973 study on labelling and mental illness.
Here is a link.

[greck]

Originally posted by lee


1) Ok, they commit her because they say she was suicidal. What is their incentive to release her if she doesn't back them up? If the says the right thing they look good.
2) If she refuses, everyday you stay in one of those places you credibility goes down.
3)Denying the problem is evidence of its severity.
4)If they release her and she was never suicidal, it looks bad for them.

1) Their primary goal is evaluation. If that evaluation comes up negative, the patient leaves.

2) Credibility in "those places" is based on the same things upon which we base credibility anywhere else. The longer you stay the more or less credibility you will develop depending on how credible you are.

3) With suicidality it MOST CERTAINLY IS NOT! Denial is big for people with addictions, trauma, anyone who's goal is to maintain some facade while not changing the dysfunction (and actually, it's not really evidence of severity in these cases either).
This is not the case with people who are suicidal. People who are suicidal do not want to maintain suicidality. They kill themselves in order to quit feeling that way in fact. People who are suicidal are usually quite honest about it when asked directly (assuming it is safe to do so). The most important thing a person can do to stop someone from completing suicide is to ask them if they are considering it.

4) again, the goal of a psychiatric hold is evaluation, assessment

[j.c.]

It's also possibly that this was a backlash. Mental Health professionals are always accused of doing too much (in this case) or not enough (recent immolation suicide by MIT student). Often, lawyers make rules based on the last big stink, and the staff has to try and follow those rules. Allowing someone who could easily be accused of being a danger to others to walk on out could be a serious legal issue. That said, your friend’s story sounds hinky. For one thing, your average fireman and EMT has seen the absolute worst of human stupidity and have a pretty good opinion (if asked, and they probably were) about stupid versus dangerous/suicidal.

Additionally – if she did indeed tell the docs “that she had not severed ties with anyone, tidied up her business, or done any of the things one normally does before suicide,” well, that’s kind of odd. (Not to mention inaccurate.) You get enough kind of odd things in a row and they add up.

[KellyM]

greck, the point is that because of the bias on the part of the evaluators, it's very rare for an evaluation to come up negative. Just the fact that an individual has been ordered to a psych eval by a physician is enough bias to lead many MHPs to assume that the individual is, in fact, deranged, and thus prejudices the evaluation. Some of the more egregious examples are documented in legal and psychological literature.

Once a physician makes the decision to suspect that an individual is mentally ill, the mental health system will bend over backwards to support that physician's conclusion, even if it is incorrect. This is, in my opinion, the operation of the "thin green line" and reflects the fact that a doctor who inappropriately orders a patient confined can be subject to substantial legal liability. The MHS protects the doctor and the hospital by always finding cause for the confinement and then extorting the admission and waiver from the patient during the forced confinement (by making release conditional on signing the admission and waiver).

As to funding: since the state pays for people who don't otherwise have insurance, you can always get at least a few weeks of funding for just about anyone. And most college students have at least some form of insurance that'll pay at least for sixty days or so, and generally you can extort the admission that protects everyone from a lawsuit by then. The cost of sixty days of mental health confinement is nothing compared to that of a multimillion dollar libel or malpractice judgment.

[flight]

greck, I am absolutely sure it happened. She wasn't happy about talking about it and was very embarassed and I had confirmation elsewhere. As to how accurate her story is, well who knows. I can very easily see this person making the honest BBQ mistake. Though smart she is not very aware.

Though she was not suicidal, she was mildly depressed, so my guess is that they took this as evidence that it must have been a suicide attempt and refused to believe otherwise. As she is in this field herself, she has since discovered that this sort of thing is not too uncommon.

Also, it is entirely possible that much of this was CYA on the part of the doctors. There is currently a law suit pending in my town against a psychiatrist who's patient went nuts and shot a couple people on campus. Maybe they were extra paranoid because of this.

[BytopianDream]

One of the biggest problems with some psychological diagnoses are that the criteria for them are so broad or undefined.

Do you sleep too much, or not enough?
Do you eat too much, or not enough?
Do you feel tired and anxious most of the time?

If so you are depressed!!! (Never mind that this could refer to 90% of all adults in America.)

ADHD is a similiar diagnosis.
Do you have trouble concentrating in school while the teacher reads War & Peace in a monotone voice?
Does your mind wander when you are supposed to be doing 500 long division problems?
You got ADHD!!! Give that boy some Ritalin.

The suicide prevention is important. I would prefer to err on the side of caution. I feel for your friend. I think I would freak out like her and start spewing DSM-IVR stuff. Then, of course, they would commit me for being in psych... I mean only nutsoids go into psychology.

[AHunter3]

It doesn't strike me as being anything out of the ordinary. Anyone can be committed involuntarily.

At least she caught on pretty quickly how to push their buttons and obtain release.

[Hamlet]

Here in Illinios, the emergency involuntary commitment of an adult person without a guardian is controlled by statute. Before an emergency involuntary commitment, there are many checks to assure that it is done fairly. The petitioner (the person asking somebody be involuntarily committed) must show:

1) "Immediate hospitalization is necessary for the protection of such person or others from physical harm."

2) "A detailed statement of the reason for the assertion that the respondent is subject to involuntary admission, including the signs and symptoms of a mental illness and a description of any acts, threats, or other behavior or pattern of behavior supporting the assertion and the time and place of their occurrence."

3) Any interest the petitioner has (financial, legal, etc.) that may make it a conflict with the rights of the person.

4) A list of witnesses to these facts.

5) Lying in the petition is a crime.

Then, once the petition is completed, it must be accompanied by a certification.

"The petition shall be accompanied by a certificate executed by a physician, qualified examiner, or clinical psychologist which states that the respondent is subject to involuntary admission and requires immediate hospitalization. The certificate shall indicate that the physician, qualified examiner, or clinical psychologist personally examined the respondent not more than 72 hours prior to admission. It shall also contain the physician's, qualified examiner's, or clinical
psychologist's clinical observations, other factual information relied upon in reaching a diagnosis, and a statement as to whether the respondent was advised of his rights under Section 3-208.

If it is not possible to get a certfication, the petition must include the additional information:

1. the petitioner believes, as a result of his personal observation, that the respondent is subject to involuntary admission;
2. a diligent effort was made to obtain a certificate;
3. no physician, qualified examiner, or clinical psychologist could be found who has examined or could examine the respondent; and
4. a diligent effort has been made to convince the respondent to appear voluntarily for examination by a physician, qualified examiner, or clinical psychologist, unless the petitioner reasonably believes that effort would impose a risk of harm to the respondent or others.

Once that is done, a person can be involuntarily held for only 24 hours maximum to obtain a mental health evaluation.

This outlines the law surrounding an emergency involuntary commitment. Once a mental health evaluation is done, then there are a whole other group of checks on holding the person more than the original 24 hours. A copy of the petition has to be provided to the subject, an attorney can be appointed to the subject, and a hearing must be held. I've personally done plenty of these hearings, and if there is truly a question whether somebody should be held, then the hearing officer will generally release the person.

I highly doubt the facts contained in the OP are complete and true. There are some important facts missing, such as the paperwork and evaluations that had to have been done to hold the woman, etc. There are many checks to make sure this law is only used in those rare cases where it is necessary to protect a person's life, and it is a rare case indeed where it is abused. Speculating that the doctor had an interest in the apartment, or some other underhanded motive involved is just plain silly.

[Hamlet]

Here in Illinios, the emergency involuntary commitment of an adult person without a guardian is controlled by statute. Before an emergency involuntary commitment, there are many checks to assure that it is done fairly. The petitioner (the person asking somebody be involuntarily committed) must show:

1) "Immediate hospitalization is necessary for the protection of such person or others from physical harm."

2) "A detailed statement of the reason for the assertion that the respondent is subject to involuntary admission, including the signs and symptoms of a mental illness and a description of any acts, threats, or other behavior or pattern of behavior supporting the assertion and the time and place of their occurrence."

3) Any interest the petitioner has (financial, legal, etc.) that may make it a conflict with the rights of the person.

4) A list of witnesses to these facts.

5) Lying in the petition is a crime.

Then, once the petition is completed, it must be accompanied by a certification.

"The petition shall be accompanied by a certificate executed by a physician, qualified examiner, or clinical psychologist which states that the respondent is subject to involuntary admission and requires immediate hospitalization. The certificate shall indicate that the physician, qualified examiner, or clinical psychologist personally examined the respondent not more than 72 hours prior to admission. It shall also contain the physician's, qualified examiner's, or clinical
psychologist's clinical observations, other factual information relied upon in reaching a diagnosis, and a statement as to whether the respondent was advised of his rights under Section 3-208.

If it is not possible to get a certfication, the petition must include the additional information:

1. the petitioner believes, as a result of his personal observation, that the respondent is subject to involuntary admission;
2. a diligent effort was made to obtain a certificate;
3. no physician, qualified examiner, or clinical psychologist could be found who has examined or could examine the respondent; and
4. a diligent effort has been made to convince the respondent to appear voluntarily for examination by a physician, qualified examiner, or clinical psychologist, unless the petitioner reasonably believes that effort would impose a risk of harm to the respondent or others.

Once that is done, a person can be involuntarily held for only 24 hours maximum to obtain a mental health evaluation.

This outlines the law surrounding an emergency involuntary commitment. Once a mental health evaluation is done, then there are a whole other group of checks on holding the person more than the original 24 hours. A copy of the petition has to be provided to the subject, an attorney can be appointed to the subject, and a hearing must be held. I've personally done plenty of these hearings, and if there is truly a question whether somebody should be held, then the hearing officer will generally release the person.

I highly doubt the facts contained in the OP are complete and true. There are some important facts missing, such as the paperwork and evaluations that had to have been done to hold the woman, etc. There are many checks to make sure this law is only used in those rare cases where it is necessary to protect a person's life, and it is a rare case indeed where it is abused. Speculating that the doctor had an interest in the apartment, or some other underhanded motive involved is just plain silly. Almost as silly as it not being out of the ordinary and that "Anyone can be committed involuntarily."

[TVAA]

But all of those steps require relying on the opinions of individuals.

Tobacco executives testifying before Congress all swore that they didn't believe that cigarettes caused cancer. Oh, sure -- they'd seen countless studies showing a link, but they didn't believe it.

How is it possible to prove that a physician didn't honestly believe something? If the physicians claims that the OP-girl's actions and speech gave him an intuitive sense that she was trying to kill herself, how can we determine if he's not telling the truth?

[AHunter3]

This is why the psychiatric inmates' liberation movement wants "mental health" commitment to refer back to the more general laws for declaring someone incompetent.

There are decent safeguards built in to prevent Creepazoid Pennybags from having Rich Uncle Pennybags declared incompetent just because he wants control of his uncle's estate.

There is no reason and no excuse for a shadow process to exist for treating someone as incapable of making their own treatment decisions solely because they are alleged to suffer from a "mental illness". If I am schizophrenic (and the doctors did say that I am, which is pretty much the functional definition of it if you see what I mean), but cannot be shown to be incompetent through the workings of a regular competency hearing, then my schizophrenia, and my decisions about treatment or lack thereof, are my business and no one else's. (Similarly, if I enjoy the mental condition I'm in and turn down offers of psychiatric treatment and then go on to commit crimes, I should be subject to the same laws and punishments that would be applicable to a non-schizophrenic committing the same crimes).

Commitment hearings in NY basically work like this: a special mental hygiene court that only hears cases of this nature is convened, often right on the grounds of the psychiatric hospital; the psychiatrist's testimony carries the weight of expert opinion, and, since the hearing is occurring at all, that means the psychiatrist is going to say that the subject of the hearing is mentally ill and lacks insight into his or her condition (and is therefore/and/or) is a danger to him/herself and/or others. The subject of the hearing gets to explain, as a nonexpert whose testimony is not impartial and is already impugned as psychotic babbling, why he or she does too have insight into his/her condition and does not need or want psychiatric treatment (a difficult maneuver when "lack of insight" is defined as "doesn't understand the need for treatment").

Volunteers from Mental Hygiene Legal Services are appointed to represent the subject but many are undertrained and often do not take an adversarial role (i.e., do not argue and present evidence supporting the subject's right to refuse forced treatment). A strategically savvy subject with the wherewithal to pull it off will have obtained an independent psychiatrist's opinion (therefore coming in with a dissenting expert opinion) or, lacking the connections/money to do that, will request independent evaluation in a separate psychiatric setting rather than using the observations of the doctor or other doctors at the same facility to support the doctor's position.

Some judges are good and fair, many are rubber-stamp weilders, and more than a few are dedicated to the principle that it is the court's responsibility to keep all lunatics locked up for the protection of the community.

In NY, if anyone other than a police officer draws the attention of a psychiatrist to your questionable behavior and the psychiatrist decides that you may be in need of treatment whether you agree or not, the psychiatrist can have you taken by the police to a psychiatric facility where an admitting psychiatrist will supply the second concurring psychiatric opinion (usually automatically, though it isn't supposed to be), and then they can hold you for 72 hours' observation before designating you as "involuntary". Only after you have been deemed "involuntary" is a commitment hearing scheduled, so it doesn't occur immediately.

If, on the other hand, a police officer observes your behavior and decides that you are nutty and dangerous (to self or others), you can be taken and held in a psychiatric facility for 30 days before they are obliged to convene a hearing.

The psychiatric facility is not obliged to present you in the courtroom in an undrugged state or in street clothes, so at your commitment hearing you may be in hospital robes and slippers or even in a straitjacket, and if, in the hours prior to your hearing, a psychiatrist or staff nurse thought medication was called for, your brain may be full of Prolixin or Haldol.

The judge is not obligated to speak to you or allow you to speak in your own hearing, and some do not.

[lee]

Hamlet, it is attitudes like yours that make abuse of these laws so easy and ubiquitous. You are so ready to doubt this person and believe her accusers simply because they are mental health professionals and she is accused of being mentally ill.

Really, one can't expect much from a profession that gave us the Minnesota Multiphasic Personality Inventory (MMPI). This test was designed by finding out how mental patients with known diagnoses answered a set of questions. If you answer like a schizo, voila you are a schizo. The problem with the design is that they did not even bother to get a wide sample of people who do not have a diagnoses to correlate against, so it would be possible to test sane. For all the test designers knew from their studies, it is entirely possible that many perfectly sane people could test as schizo. One excuse for this is that not having a diagnosis does not mean you are sane, just you have not yet been diagnosed. Mind you, it is supposed to be a tool used in conjuntion with others including patient interviews, but often it is interpreted by itself.

There are plenty of mental health professionals who are competant and ethical. All it takes is 2 that aren't to get a sane person committed.

[Hamlet]

Originally posted by TVAA
But all of those steps require relying on the opinions of individuals.

Of course it does. It is nigh but impossible to have completely objective test for "Mentally Ill" or "danger to himself or others". That doesn't mean we don't do it at all.

Originally posted by TVAA
Tobacco executives testifying before Congress all swore that they didn't believe that cigarettes caused cancer. Oh, sure -- they'd seen countless studies showing a link, but they didn't believe it.

People lie. And that helps exactly how? They've made it a crime to lie on the petition and the certification and in testimony.

Originally posted by TVAA
How is it possible to prove that a physician didn't honestly believe something? If the physicians claims that the OP-girl's actions and speech gave him an intuitive sense that she was trying to kill herself, how can we determine if he's not telling the truth?

Why would you. Pointing out that these kinds of determinations are subject to opinion and speculation does not mean that we should not be doing it.

[Hamlet]

Originally posted by AHunter3
There are decent safeguards built in to prevent Creepazoid Pennybags from having Rich Uncle Pennybags declared incompetent just because he wants control of his uncle's estate.

Those protections are not just for those occasions, but also for all cases.

Originally posted by AHunter3
There is no reason and no excuse for a shadow process to exist for treating someone as incapable of making their own treatment decisions solely because they are alleged to suffer from a "mental illness".

I agree. That is why there is no "shadow process" but a process that has numerous checks on potential abuse and which require hearings to be conducted.

Originally posted by AHunter3
If I am schizophrenic (and the doctors did say that I am, which is pretty much the functional definition of it if you see what I mean), but cannot be shown to be incompetent through the workings of a regular competency hearing, then my schizophrenia, and my decisions about treatment or lack thereof, are my business and no one else's. (Similarly, if I enjoy the mental condition I'm in and turn down offers of psychiatric treatment and then go on to commit crimes, I should be subject to the same laws and punishments that would be applicable to a non-schizophrenic committing the same crimes).

I don't understand the difference between incompetence and emergency involuntary commitment. In Illinois, the finding of involuntary commitment necessitates a finding of incompetence, albeit temporarily.

Your description of commitment hearings in NY sounds much like that here in Illinois. However, I was taken aback by your statement:

If, on the other hand, a police officer observes your behavior and decides that you are nutty and dangerous (to self or others), you can be taken and held in a psychiatric facility for 30 days before they are obliged to convene a hearing.

I cannot believe that in N.Y. you can be committed for 30 days based on nothing other than a police officers word. I know of no State that allows that.

[Hamlet]

Originally posted by lee
Hamlet, it is attitudes like yours that make abuse of these laws so easy and ubiquitous. You are so ready to doubt this person and believe her accusers simply because they are mental health professionals and she is accused of being mentally ill.

You know, you do have a modicum of a point here that indeed I do trust 2 trained mental health professionals and a third person have a better view into the mental health of a possibly mentally ill person. It is possible that there are abuses of the system, I've never seen nor heard about it. However, the potential for abuse should not mean we do away with involuntary commitments.

Originally posted by lee
Really, one can't expect much from a profession that gave us the Minnesota Multiphasic Personality Inventory (MMPI). This test was designed by finding out how mental patients with known diagnoses answered a set of questions. If you answer like a schizo, voila you are a schizo. The problem with the design is that they did not even bother to get a wide sample of people who do not have a diagnoses to correlate against, so it would be possible to test sane. For all the test designers knew from their studies, it is entirely possible that many perfectly sane people could test as schizo. One excuse for this is that not having a diagnosis does not mean you are sane, just you have not yet been diagnosed. Mind you, it is supposed to be a tool used in conjuntion with others including patient interviews, but often it is interpreted by itself.

Putting your bias against the profession aside, the MMPI-2 (it was revised in 1989) has been accepted for use in courts all over the United States. It is merely a tool, like any other tool it needs to be used properly, to help the mental health professional make determinations, not an end-all be all. I know of absolutely no psychologists or psychiatrists who would ever rely solely on the MMPI-2, and it is actually unethical to do so.

Originally posted by lee
There are plenty of mental health professionals who are competant and ethical. All it takes is 2 that aren't to get a sane person committed.

And a third person to petition. And a mental health hearing officer. And a prosecutor. And the defense attorney. And the defense's expert, if requested. And every mental health professional who treats the person. And every one who testifies at the inital hearing and who file the supplemental information at the subsequent hearings. Is it possible for abuse to occur, I guess. But it would take an awful lot of doing by an awful lot of people. Not to mention the risk each person to do it takes with their own professions and lives.

[TVAA]

The problem is not that corrupt professionals will lie about their opinions.

The problem is that the objective justification for and accuracy of those opinions is never called into question.

How do these professionals go about determining whether these people are a threat to themselves or others? Unless they state they're trying to kill themselves or others, or they were caught in a situation that is unambiguously dangerous to themselves or others, what are they basing their impressions on?

[Hamlet]

Originally posted by TVAA
The problem is that the objective justification for and accuracy of those opinions is never called into question.

Sure it is. The petition and the certificate are looked over by a judge. The hearing officer considers all the evidence also. As AHunter raised, it is possible that some of these may be rubber stamps, however, the person possibly subject to involuntary commitment can demand his/her own mental health person to do an evaluation also. In my experience, if there is even the slightest doubt as to the propriety of the commitment, the subject's attorney will request a third person conduct an additional evaluation.

Originally posted by TVAA
How do these professionals go about determining whether these people are a threat to themselves or others? Unless they state they're trying to kill themselves or others, or they were caught in a situation that is unambiguously dangerous to themselves or others, what are they basing their impressions on?

Same way as every one else does. Their opinions aren't pulled out of thin air, they look at what the subject has said (I want to be dead), what the subject has done (attempted suicide), whether the subject cares for themselves (starving themselves), whether they've acted violently (attempting to cut their mom's head off), etc. There has to be some objective basis to show that the subject is a danger to himself or others, and the burden of establishing it is on the person advocating the commitment.

[KellyM]

Hamlet: assuming the subject has an attorney, and not just one of those clowns that they have represent indigents. Note that if you're being held in a lockdown ward juiced to the gills with Haldol, it is very difficult to contact your attorney.

You obviously have more trust in the system that those of us who have seen it fail do. Pray that you are never on the wrong end of a committment hearing.

[greck]

Originally posted by KellyM
greck,
1)the point is that because of the bias on the part of the evaluators, it's very rare for an evaluation to come up negative.

2)As to funding: since the state pays for people who don't otherwise have insurance, you can always get at least a few weeks of funding for just about anyone.

3)and generally you can extort the admission that protects everyone from a lawsuit by then.

1) Having been said evaluator, I can tell you that this is absolutely not true. It would be fun if you could cite this though.

2) I think all states are now using private companies to manage their medicaid monies, they do so to try spending less.
You speak as though you have acutal experience getting at least a few weeks for people, What utilization review department do you work in? Where I come from it's a pain to get funding for people who genuinely need it, let alone someone who doesn't.

3) this cracks me up. At what point have you actually participated in the extortion of information from the mentally ill? And could you tell me how?

[Hamlet]

Originally posted by KellyM
Hamlet: assuming the subject has an attorney, and not just one of those clowns that they have represent indigents. Note that if you're being held in a lockdown ward juiced to the gills with Haldol, it is very difficult to contact your attorney.[/b

The vast majority of attorneys representing the subject of a potential involuntary commitment are very concerned and careful to protect their client's interests. Oftentimes they are put into a tough position of deciding whether to advocate for the release of somebody, when they are convinced that the release may do great harm to their client. In cases such as that, where their own client is clearly mentally ill and a danger to himself/herself, the attorney may not fight tooth and nail, but, in general, they are careful to protect the rights of their client.

Originally posted by KellyM
You obviously have more trust in the system that those of us who have seen it fail do. Pray that you are never on the wrong end of a committment hearing.

Not only have I never seen it fail, I've never seen a close case. Involuntary commitment is such an extreme, it is generally reserved for, and only ordered in, the most troublesome cases. I highly doubt I'll ever be on the wrong end of one, though.

[KellyM]

greck, I've watched mental health professionals attempt to extort those admissions on several occasions, and have accounts from others who I trust of having seen the same thing done. Generally they tell you that "if you don't sign this paper we'll have to go to court and have you committed". The paper states that you consent to treatment, admit that they had just cause to involuntarily restrain you, and release them from all claims related to your original hold. (You are not encouraged to read the paper.) If you don't sign it, they put you on maximum restrictions and label you as "uncooperative". This is extortion, and it's SOP as far as I know at virtually every facility that provides mental health services.

[KellyM]

Hamlet, the vast majority of people in involuntary committment proceedings are either unrepresented or represented by overworked, underpaid public defenders who often only have time to read a file summary before the hearing.

It is true that most cases do not actually come to a hearing because of the extortion process I mentioned in my last post; individuals are coerced into signing away their freedom instead of having it taken from them. Not much of an improvement.

[TVAA]

There is no objective meaning to the phrase "mentally ill". There are no objective methods for determining whether any person is mentally ill.

Opinion, tradition, and convention are not satisfactory methods for determining the truth.

Hamlet: How do they determine whether someone has in fact attempted to kill themselves?

The OP describes a scenario that does happen. People are ignorant or foolish enough to light significant fires in poorly ventilated areas. How can someone prove that they weren't trying to kill themselves?

What criteria must be met to demonstrate that a person isn't mentally ill?

[Hamlet]

Originally posted by KellyM
Hamlet, the vast majority of people in involuntary committment proceedings are either unrepresented or represented by overworked, underpaid public defenders who often only have time to read a file summary before the hearing.

It is impossible (well not impossible, but illegal) for the person to be "unrepresented" at the hearing. No hearing officer and no prosecutor would allow it. And the counsel appointed when I've done it were all specifically trained and specializing in, these kinds of cases. It was never somebody who didn't know what was going on and trying to work with their client.

Originally posted by TVAA
There is no objective meaning to the phrase "mentally ill". There are no objective methods for determining whether any person is mentally ill.

If you want to debate the propriety of the entire mental health field, I fear you might want to start another thread. Your question as to whether anyone can be considered mentally ill, when there is no real way to determine "mental illness" is too broad for this discussion and too circular in logic.

Originally posted by TVAA
Opinion, tradition, and convention are not satisfactory methods for determining the truth.

In one breath you say there is no objective "truth" whether somebody is mentally ill or not, and the next you say you can't determine the truth by opinion, etc. It follows logically, but tells us nothing relevant.

Originally posted by TVAA
Hamlet: How do they determine whether someone has in fact attempted to kill themselves?

Please stop it with these deliberately obtuse kinds of questions. They do it just like everybody else on the fricking planet do it, by looking at the specific facts of the case. Are some cases (the OP) harder to determine than others (gunshot wound to the temple and a suicide note)? Yes, but that has nothing to do with whether or not the determination can or should be made. The burden is on the petitioner to prove that the person is a danger to himself or others, and if they can't meet that burden, the person shouldn't be committed.

Originally posted by TVAA
What criteria must be met to demonstrate that a person isn't mentally ill?

Once again, the burden is on the petitioner to prove that the subject IS mentally ill. I don't have the complete knowledge, nor the patience, to explain the entirety of the field of mental health to you.

[greck]

KellyM
Generally they tell the person alot more than that. Generally they ask alot more questions too. Generally they gather a good amount of information and consult with others before deciding to pursue an involuntary admit.

And yes, "maximum restrictions" much in the same way a cast is "maximum restriction" for a broken leg.
those restrictions are a pain to implement, document, and staff. No one wants them if they're not absolutely necessary.

And what exactly qualifies you as an authority on SOP at virtually every facility that provides mental health services?

[TVAA]

There are no clear and unambiguous standards by which mental illness and mental health are judged, Hamlet. While there is always a degree of uncertainty in medical diagnosis, psychiatry is notorious for relying on practitioner judgment for making determinations, and practitioner judgment in medicine is notoriously falliable (at least, in fields where objective standard exist by which those judgments can be validated).

[Hentor the Barbarian]

TVAA, you should know better than to be making such rash and ill-considered statements, or your training has been particularly poor. You would be better served by stating that the DSM criteria for certain diagnoses of mental illness are more well-defined or function better to identify people suffering from some conditions than others.

The characterizations of our diagnostic framework, inpatient hospitalization and third party reimbursement, and the commitment procedures that are being made here reflect a true lack of knowledge about these issues.

For example, the original MMPI was validated on a "normal" sample, excepting IIRC that they were relatives of the original mentally ill sample. The MMPI is an empirically driven measure, meaning that yes, it works by seeing if you answer in the same manner that someone else with a particular mental illness did. Hamlet is absolutely correct that it is used only as an aide to other clinical measures and tools.

DSM-IV symptoms are not simply "do you do more or less of something or other." For example, depression symptoms are: depressed mood most of the day, nearly every day; loss of interest or pleasure in activities normally enjoyed, nearly every day; change in appetite (which can be reduced or increased); change in sleep (which can be insomnia or hypersomnia); being slowed down or feeling restless; fatigue; feelings of hopelessness, worthlessness or excessive guilt; problems with concentration; and recurrent thoughts of death, suicidal ideation or suicide attempt. Five of these nine symptoms must be present for a period of two weeks. A fairly large amount of research has gone into and continues to go into validating these symptoms, and we are always hopeful that we can improve our nosological framework.

These are the criteria to determine depression or its absence. What other mental illness would you like to discuss?

I have to say that the most difficult instances of providing treatment for me have been for folks with bipolar disorder who are manic. They seem to have the greatest difficulty recognizing that things aren't exactly going smoothly for them. Discussions like this one remind me of the woman who was brought in after being missing from her family for 4 or 5 days. When she was found, she was three hours away in a hotel room with a young man not her husband, with some drugs of abuse. I felt terrible for her, and still do, but the majority of my time with her was spent listening to how I was the arm of the oppressive mental health fascists she was working to fight against. I have no doubt that in her retelling of the incidents around that time today, she might omit a fair bit of the details.

I have never seen anyone railroaded into treatment of any kind. I have never seen anyone mis- or unrepresented at a commitment hearing.

Well, enough of my yappin'.

[TVAA]

Originally posted by Hentor the Barbarian
TVAA, you should know better than to be making such rash and ill-considered statements, or your training has been particularly poor. You would be better served by stating that the DSM criteria for certain diagnoses of mental illness are more well-defined or function better to identify people suffering from some conditions than others.

Quite the opposite. First, it's widely acknowledged that those standards are often fudged or ignored. In order to receive compensation for treatment, insurance companies often require that a patient receive a diagnosis from the DSM; practitioners have been known to make diagnoses in clinical situations that technically don't satisify the DSM criteria.

For example, the original MMPI was validated on a "normal" sample, excepting IIRC that they were relatives of the original mentally ill sample.

That alone is a major problem, since families often share habits and personality traits.

The MMPI is an empirically driven measure, meaning that yes, it works by seeing if you answer in the same manner that someone else with a particular mental illness did.

...because there are no physiological diagnostic tests to show whether a person is mentally ill. There have been countless attempts to find biological indicators, and a few that were even widely accepted for a time... but they were all shown to be inaccurate and inspecific.

Hamlet is absolutely correct that it is used only as an aide to other clinical measures and tools.

But ALL clinical measures and tools ultimately are secondary. Clinical judgment is primary -- as the public is often reminded, "only trained professionals can diagnose depression." This is because professionals have been exposed to the diagnostic habits of other professionals and have internalized them to some degree.

The ability to predict how other professionals will diagnose does not indicate that those judgments have any foundation.

DSM-IV symptoms are not simply "do you do more or less of something or other." For example, depression symptoms are: depressed mood most of the day, nearly every day; loss of interest or pleasure in activities normally enjoyed, nearly every day; change in appetite (which can be reduced or increased); change in sleep (which can be insomnia or hypersomnia); being slowed down or feeling restless; fatigue; feelings of hopelessness, worthlessness or excessive guilt; problems with concentration; and recurrent thoughts of death, suicidal ideation or suicide attempt. Five of these nine symptoms must be present for a period of two weeks. A fairly large amount of research has gone into and continues to go into validating these symptoms, and we are always hopeful that we can improve our nosological framework.

Important note: these criteria merge typical and atypical depression together. Isn't this a bit odd, since the treatments and responses required are often different?

I have no doubt that in her retelling of the incidents around that time today, she might omit a fair bit of the details.

That sounds probable. There are many cases where the individuals are not withholding pertinent information; my story, while (thankfully!) less than serious, is one.

I have never seen anyone railroaded into treatment of any kind. I have never seen anyone mis- or unrepresented at a commitment hearing.

Others have. Perhaps you're not looking carefully enough.

[KellyM]

Originally posted by TVAA
Quite the opposite. First, it's widely acknowledged that those standards are often fudged or ignored. In order to receive compensation for treatment, insurance companies often require that a patient receive a diagnosis from the DSM; practitioners have been known to make diagnoses in clinical situations that technically don't satisify the DSM criteria.

To be sure. My psychologist lists, officially, my diagnosis as "Adjustment Disorder NOS" when it should more properly be one of the gender identity disorder codes. He does this because most insurance will pay for adjustment disorder, but will not pay for GID. I don't meet the criteria for adjustment disorder.

The system can, and is, manipulated. In this case, it's the insurance system, but the involuntary committment system is also prone to manipulation and is manipulated, at least from time to time if not as a matter of course.

[TVAA]

Quite right.

Oh, and Hentor:

Since the DSM defines what the mental illnesses are, or at least what they're considered to be, it follows that the criteria they list are 100% effective at determining whether a person has them.

Of course, we could accept that those criteria are necessarily at least incomplete... in which case we have no particular reason to presume that the DSM criteria have anything to do with whether any person has a condition.

[Hamlet]

Originally posted by KellyM
But the involuntary committment system is also prone to manipulation and is manipulated, at least from time to time if not as a matter of course.

Change "prone" to "possible," and "time to time if not as a matter of course" to "extremely rarely," and you would be closer to the truth. The huge difference between involuntary commitments and insurance claims is the level of statutory and profession protection of the patient. As I've stated over and over, the protections in the involuntary commitment procedure make it very difficult to abuse. Comparing it to some doctor's misidentification of a diagnosis for insurance purposes and overstating the frequency of occurence (matter of couse? Tis to laugh) are cheap shots with no intellectual integrity. And just because mental health field is not nearly as objectively verifiable as mathmatics, does not lead to the conclusion that there exists abuse or ascribing evil motives to mental health professionals.

[Hentor the Barbarian]

Originally posted by TVAA
Quite right.

Oh, and Hentor:

Since the DSM defines what the mental illnesses are, or at least what they're considered to be, it follows that the criteria they list are 100% effective at determining whether a person has them.

Of course, we could accept that those criteria are necessarily at least incomplete... in which case we have no particular reason to presume that the DSM criteria have anything to do with whether any person has a condition.

Quite a foolish statement, actually. You seem to be suggesting throughout your posts that because there is no as yet accepted biological or physiological marker we can use to id mental illness, there is no mental illness. Is this your point?

Or is it rather that because we have no such markers, our best alternatives are not acceptable?

We use DSM as definitions, yet also recognize that they are incomplete - they do not determine whether a condition is present 100% of the time. (I would ask whether we have any conditions for which our criteria identify them 100% of the time, but I don't want to interrupt your agenda.)

Why does it then follow that they have nothing to do with whether a person has a condition? Are you saying that they must be 100% effective or not at all?

I have no idea what you were referring to about typical versus atypical depression, but if you have identified and are using typologies, surely others might as well. Did you not mean to convey information just then? Is your typology 100% effective? By your own insinuations, you should not use it.

There are certainly cases where clinical judgment is involved, and provisional diagnoses are given. This is used to indicate that the psychologist believes that the criteria for a condition is or will be met, but is not sure.

As to not looking hard enough, I can only say what I have and haven't seen. I am not on a crusade.

[Hentor the Barbarian]

Originally posted by Hamlet
The huge difference between involuntary commitments and insurance claims is the level of statutory and profession protection of the patient. As I've stated over and over, the protections in the involuntary commitment procedure make it very difficult to abuse. Comparing it to some doctor's misidentification of a diagnosis for insurance purposes and overstating the frequency of occurence (matter of couse? Tis to laugh) are cheap shots with no intellectual integrity.

Quite correct, Hamlet and I had fallen for the switch in arguments without really noting it.

[TVAA]

Originally posted by Hentor the Barbarian
We use DSM as definitions, yet also recognize that they are incomplete - they do not determine whether a condition is present 100% of the time. (I would ask whether we have any conditions for which our criteria identify them 100% of the time, but I don't want to interrupt your agenda.)

Why does it then follow that they have nothing to do with whether a person has a condition? Are you saying that they must be 100% effective or not at all?

Diagnostic medical tests are rarely 100% effective. However, there are still criteria by which doctors can, in theory, determine whether a person has the disease: they're the disease's defining characteristics.

For example, a person can't have chicken pox if they're not infected with a particular type of virus. Tests may or may not be able to detecting the virus in all the people who have it, and they might make mistakes by generating false positives.

The criteria in the DSM have not been established to correspond with an underlying condition -- instead, they define the condition. Mental illnesses are defined by their symptoms, whereas most medical illnesses are defined by their etiologies. Those criteria were not established through rigorous statistical studies. They were voted on by the members of the APA, and they continue to be voted on and changed as time passes as clinicians change their opinions about what mental illnesses should be considered to be.

I have no idea what you were referring to about typical versus atypical depression, but if you have identified and are using typologies, surely others might as well. Did you not mean to convey information just then? Is your typology 100% effective? By your own insinuations, you should not use it.

Typical and atypical depression is a well-established distinction. You've never heard of it? Why am I not surprised...

There are certainly cases where clinical judgment is involved, and provisional diagnoses are given. This is used to indicate that the psychologist believes that the criteria for a condition is or will be met, but is not sure.

Clinical judgment is ALWAYS involved.

As to not looking hard enough, I can only say what I have and haven't seen. I am not on a crusade.

Neither am I. I simply want the truth.

[TVAA]

The point is not that mental heal professionals are evil, scheming manipulators who go around committing perfectly healthy people.

The point is that the system has certain weaknesses that make it vulnerable to well-meaning professionals who want to help people but become overzealous in doing so.

[Hentor the Barbarian]

Originally posted by TVAA
Typical and atypical depression is a well-established distinction. You've never heard of it? Why am I not surprised...

This statement is well below you, Vorlon, and I am surprised. As you are aware, I did not say I was unfamiliar with them, and you have avoided the point that you are employing a typology while criticizing another typology. [/quote]

I simply want the truth.

I get the impression that you can't handle the truth.

[AHunter3]

The alleged "mental illness" or lack thereof should not even come up as relevant subject matter in a competency hearing. It has no bearing on the subject.

Danger to self or others, except insofar as it demonstratably stems from an inability of the person in question to plan, make observations, and comprehend likely outcomes, is also not relevant, even where it can be supported by explicit evidence of actual behavior rather than prediction. You have the right to make incredibly stupid decisions (and the obligation to be held responsible for having made them) as long as you are competent.

Hearings into competency should not be segregated in such a way that there would exist courts into which only the allegedly "mentally ill" are brought. They need to have their hearings in the same venue as any other competency hearing. The tendency I've observed is for the standard competency hearing to operate from an assumption of competency, which must be challenged by the parties alleging a lack thereof; whereas psychiatric commitment hearings tend to operate from an assumption that "you wouldn't be here if you didn't need it", leaving the burden of demonstrating otherwise to the person in question.

-----

I'd like to know where Hamlet lives, as his descriptions make it sound like a much more reasonable place to live than any place I've been.

[TVAA]

Originally posted by Hentor the Barbarian
This statement is well below you, Vorlon, and I am surprised. As you are aware, I did not say I was unfamiliar with them, and you have avoided the point that you are employing a typology while criticizing another typology.

Then you know that those are not separate typologies.

The DSM criteria are presented by definitive -- they are completely accurate not because they match an unknown phenomenon, but because their criteria define the category of, say, "depression".

At the same time, these definitive criteria are acknowledged to be secondary to clinical judgment and opinion.

Don't you see a problem with this?

[flight]

Originally posted by Hamlet
The vast majority of attorneys representing the subject of a potential involuntary commitment are very concerned and careful to protect their client's interests. Oftentimes they are put into a tough position of deciding whether to advocate for the release of somebody, when they are convinced that the release may do great harm to their client. In cases such as that, where their own client is clearly mentally ill and a danger to himself/herself, the attorney may not fight tooth and nail, but, in general, they are careful to protect the rights of their client.Not only have I never seen it fail, I've never seen a close case. Involuntary commitment is such an extreme, it is generally reserved for, and only ordered in, the most troublesome cases. I highly doubt I'll ever be on the wrong end of one, though.

As far as legal representation goes, she could not afford an attorney so she had one oppointed to her. At least according to her the attorney didn't do a damn thing, and was more of a spectator. She fought the whole process bitterly, and believes that how pissed off she was at the thought of involuntary incarceration worked against her, making her look less competent and reasonable. Then again, how many of us would look reasonable when someone is telling us it is reasonable that we are going to get locked up without having done anything.

If I recall correctly she was held for three days. She never got back to her apartment after having been takin to the hospital, so apparently the hearing came real quick. She was released only when someone would legally sign her out, thereby taking responsibility for her. As she was new in town and it was spring break she only had one friend in town and that person (also a psych student) refused to do it because she thought that if anything happened to my friend then her insurance rates as a psychologist would go up. That is really a Pit topic though. Eventually a friend from out of town drove in to get her out of the hospital. If he had not been there there was not a preset limit on how long she would be in the hospital (this is how I understand it, but we are no longer dating and I am not about to ask about clarrification about this).

[Hamlet]

Originally posted by AHunter3
I'd like to know where Hamlet lives, as his descriptions make it sound like a much more reasonable place to live than any place I've been.

Iowa and Illinois. I've done these kinds of cases in both.

[greck]

Originally posted by TVAA


The DSM criteria are presented by definitive -- they are completely accurate not because they match an unknown phenomenon, but because their criteria define the category of, say, "depression".

[/b]

Lemmie get this straight, without the DSM to define it, there would be no such thing as depression?
does schizophrenia work the same way? cause I could just rip those pages out of my DSM right now and save some of my clients a whole lot of trouble.....

[AHunter3]

TVAA is right. In the absence of a laboratory test -- you know, a test for 'n-schizophrenase' or something -- the definition of the malady is the list of symptoms, perhaps with a qualifier like "displaying 4 or more of these 6 symptoms".

And then if you play fast and loose with that definition, as the field of psychiatry does in fact do, you end up with "well, I know it when I see it". Or, as I put it previously, the mental illnesses are in practice defined as the possession of a psychiatric diagnosis of same.

[AHunter3]

By the way:

http://members.bellatlantic.net/~adh...ol_4/drey.html

I have more.

[TVAA]

No one has ever managed to show that people with specific emotional states are actually sick in some physically definable way.

It's entirely possible that many people who are depressed truly have something wrong with their brains. It's unlikely that the majority of them do.

Basically, greck, the category of depression requires the DSM to define it.

I wish it were possible to make people feel better by destroying the DSM... but we could eliminate the diagnostic category by doing so.