Psychology, the law, and being committed

[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.