How do we balance individual rights and public safety wrt the mentally ill?

Great Debates
#1

Without pointing fingers at any political party, how do we come together as a nation with a solution to the problem of the danger the mentally ill can potentially present to public safety, while maintaining some safeguards to individual rights?

It is clear that many states still have laws on the books that are “antiquated” with regard to dealing with the mentally ill and, if necessary, involuntarily committing those who are seen as a danger to themselves and/or others. For just one example, we can look to California’s Lanterman, Petris, Short Act (LPS Act). At the time it was written and signed into law 41 years ago, it was considered groundbreaking, and its intent was: [ul]
[li]To end the inappropriate, indefinite, and involuntary commitment of mentally disordered persons, people with developmental disabilities, and persons impaired by chronic alcoholism, and to eliminate legal disabilities;[/li]
[li] To provide prompt evaluation and treatment of persons with serious mental disorders or impaired by chronic alcoholism;[/li]
[li] To guarantee and protect public safety;[/li]
[li] To safeguard individual rights through judicial review;[/li]
[li] To provide individualized treatment, supervision, and placement services by a conservatorship program for gravely disabled persons;[/li]
[li] To encourage the full use of all existing agencies, professional personnel and public funds to accomplish these objectives and to prevent duplication of services and unnecessary expenditures;[/li]
[li] To protect mentally disordered persons and developmentally disabled persons from criminal acts.[/li][/ul] http://en.wikipedia.org/wiki/Lanterman–Petris–Short_Act

However, an in-depth, 3 year study conducted by medical professionals in the Los Angeles County Affiliates of the National Alliance for the Mentally Ill (NAMI) and the Southern California Psychiatric Society found:

*"One of the difficulties in providing continuous treatment in the community is that since these illnesses are brain disorders that affect the ill person’s reasoning, some individuals do not recognize that they are ill or that the symptoms of their condition will respond to medication. Therefore, they do not seek treatment. If hospitalized, they may be unable or unwilling to comply with treatment plans after discharge. When this occurs, the person may require involuntary treatment to protect their lives and avoid tragic social and personal consequences.

The current California law regarding involuntary treatment for mental illness – the Lanterman, Petris, Short Act (LPS Act) – was written 30 years ago before scientific knowledge advanced recognizing mental illness as a physical disorder of the brain. Its purpose was to depopulate state hospitals. It was not full realized at the time of its enactment the structure and support some people with mental illness would require to successfully participate in community life. Furthermore, over the years the act has been piecemeal amended to make it one of the most adversarial, costly and difficult to administer involuntary treatment systems in the United States. Lack of clear definition and common misinterpretation of its provisions have caused inconsistent application from county to county.

The law must be revised to incorporate modern scientific knowledge regarding the nature and treatment of mental illness in the community and to streamline its efficiency in today’s managed care environment. "*

http://www.desertpacific.mirecc.va.gov/news/lps-reform.shtml

Questions for debate:

What safeguards should be put in place to protect the public from potentially deadly consequences from the mentally ill who may pose a threat?

What safeguards should accompany those solutions, that protect the individual’s right to “control their own bodies”?

What would laws with regard to access to weapons and access to medication and treatment look like, and how effective do you believe they would they be?

Other?

#2

My inclination is that the law should allow the liberal use of involuntary psychiatric evaluation, and extremely restrictive use of involuntary psychiatric commitment. But I haven’t thought about it much beyond that.

#3

Make it a part of the routine preventative medical checkups that happen every x number of years.

#4

Erm… lots of people don’t get routine preventative medical checkups. I suspect undiagnosed mentally ill people are among those least likely to do so.

#5

So once every year or two, you go to the doctor and he decides if you should be institutionalized.

Do you see any difficulties that may arise in getting paranoid schizophrenics to follow that protocol?

Regards,
Shodan

#6

Lots of people might not get checkups, but they probably go to work or school, communicate with others personally or via the Internet, or have other interactions that would make others aware that they might be disturbed in some way.

This became an issue after the Virginia Tech shootings, after it became known that teachers, students, and health officials on campus all were aware that the shooter was mentally ill. Changes were made in Virginia to address how colleges and others might address this in the future. I don’t know whether this has been entirely successful, but it is important that states look at these issues regularly.

The reports of the commission that studied the Virginia Tech shooting is here, for anyone interested.

I note this because the same kind of thing seems to have cropped up here - this shooter was going to school and other students and teachers knew he was crazy. Some seemed to fear for their lives in the classroom. And yet nothing concrete seems to have been done.

Relying on “authorities” to handle a situation like this is a false wish - even if they have the power to do anything they won’t have any knowledge of a situation unless we direct them to act. Who directed anyone to act for Loughner? Who told anyone in authority about Cho Seung-Hui? In Cho’s case everyone involved seemed to act to minimize the situation so as not to let it get any worse for him - he then made it worse for others.

Just my contribution to the discussion.

#7

Bear in mind the aftermath of Columbine, etc. though: teachers and school administrators practically called in SWAT teams any time a student turned in an assignment even tangientially connected with violence.

#8

To steal from my own post on a different board:

Those of us who have received psychiatric diagnoses are not more violent than anyone else. We’re more unpredictable in our violence (just as we’re more unpredictable overall) but not more violent and not more likely to engage in gun-related violence.

The normal people to whom we would be compared, our control group, are less unpredictable but not less violent; their proclivity towards gun-related violence more often follows predictable trajectories but it doesn’t seem to help potential victims avoid their gun violence to the point of making them less dangerous.

The laws are written in such a way that even if that trajectory can be predicted, you can’t just lock them up for what they MIGHT DO. Racial ethnic and religions profiling, psychological typecasting, taking note of people’s companions and social peer group… they can yield statistically significant figures about the likelihood of joe average citizen to engage in gun violence. But we believe in people’s right to be judged as their individual self for what they’ve actually done. Our system rejects the notion that it is OK to abridge their rights and privileges based on their beliefs, the company they keep, their ethnic or racial makeup, and so on. Maybe our police officers scrutinze them more closely, but they still wait for an actual crime to be committed before they rush in to intervene. Are you OK with that?

We schizzies just want equal consideration. Nothing special. We’re less predictable in our propensity towards violence but that just means you’re less able to tell which of us might do something. Seems like if you’re going to start with preemptive interventions you ought to start with the normal folks whose violent behavior is more predictable?

#9

Precisely what I meant. Oh wait… no. It’s not. I meant incorporating mental health checkups into the whole preventative health-care routine. Over time it would be a big step towards changing the culture and attitude towards mental health and mental illness. Sure, people wouldn’t always go see someone, but if their doctor is recommending it or referring them for a routine check-up, things will start to change. It’s a step in the right direction. Think in terms of “long-term piece of the puzzle” instead of “perfect solution that fixes it right now.”

#10

I don’t see how that addresses the objection.

In the future, regular doctors do a mental health screening as part of their recommended annual check-up. If you fail the screening, he will recommend you for institutionalization or medication. Someone who does not want to be institutionalized or medicated will avoid the annual check-up, therefore.

What then - do we pass a law that everyone must report to a government-approved doctor once a year to be certified that you can walk around loose for another year?

You really don’t see any problems with that?

Regards,
Shodan

#11

This is a problem which lacks a satisfactory solution, even in theory.

Our society is predicated on individual consent for adults, in a host of ways. That is a pretty fundamental bedrock on which our society’s notions of freedom are built - to tamper with that raises no end of posibilities for unintended bad consequences.

Therefore, cautious people are leery of removing consent unless the evidence is overwhelming that it ought to be removed. The problem here is that the evidence is generally only “overwhelming” in hindsight of a tragedy.

Many mentally ill people do not believe that they are mentally ill, or do not want treatment. Others around them - particularly their families - may have a different opinion, but currently their options for doing anything about it are limited: they can encourage or cajole them into treatment, but that is about it; if they don’t want to go, it can be very difficult to make them go - that usually requires some sort of judicial process proving that they are a danger to self or others. That is generally the standard for “committal” or psychiatric hospitalization.

The problem here is that it can be a bit of a revolving door: guy has an episode, is “committed”, takes his meds, is no longer a danger, is discharged, stops taking his meds, has an episode …

I’ve seen this several times. What usually happens is that the family etc. simply gets worn down, ceases to be able to respond to it, gets frightened. The end result is the person with mental health issues living on the streets, occasionally getting picked up by the cops, etc.

An alternative is the so-called “community committal”.

http://www.cmha.ca/bins/content_page.asp?cid=5-33-179

#12

This is an issue that has a number of complications at even very basic levels. Identification is certainly one of them, but even at the level of definition it gets thorny. What do we mean by mental illness? I suspect that most people envision schizophrenia when the word comes up, especially in this context, but mental illness of course might be in the form of depression, ADHD, triskadekaphobia (fear of the number 13), enuresis (bed wetting), conduct disorder, alcohol dependence, anorexia nervosa, and so on and so forth. Each of these is associated with a differing overall level of threat of violence (to others or to oneself), and for any given individual, there will be variations in how likely they are to commit violence.

Further, the number of people with schizophrenia who commit handgun violence, particularly like that in the case at hand, is very small. The vast majority of the people who engage in multiple homicides with handguns do not have schizophrenia. Nor, for instance, did Timothy McVeigh, to my knowledge.

It can be quite difficult to predict the level of threat of violence for a given person – probably just about as difficult to do so if they have a mental illness as if they don’t. Mental illnesses themselves also wax and wane over time within the individual, so the presence or absence of any threat of violence associated with that disorder will be dynamic rather than fixed over time.

Furthermore, mental illnesses are categorical constructs, but they are hardly perfect reflections of reality. They do their job pretty well, but ultimately they involve some aspects of dysregulated functions within which we all show individual variabilities. Some people have hotter tempers than others, without necessarily meeting criteria for a mental illness, for example. Some people may experience greater levels of anxious feelings than others. Contexts and circumstances may evoke a violent reaction from a person who otherwise would never show that sort of behavior.

My point is that locking people up in order to stave off violence primarily on the basis of having a mental illness would result in a lot of false positives, and conversely a lot of false negatives among those you chose to let go.

I do think that states or jurisdictions that are pretty liberal about mandating evaluations, but which allow for due process for the individual throughout the process, do things as well as is possible. I just don’t want to be the one who has to put my name to the decision to not hold someone for involuntary treatment when there’s any question about the likelihood that they will commit violence.

#13

I think the question of locking people up to prevent violence is looking at the matter far too narrowly.

The real issue, in my mind, is how to avoid the downward treadmill cycle that many mentally ill people appear to travel - one that, often, ends with the mentally ill person living on the street.

I don’t really have any good answers, but all of them appear on some level to involve substituting the decision of some professional or family member for that of the mentally ill person, in how that person lives their own life; which is always going to be problematic.

Right now, the "threshold’ for that is set quite high: a provable danger to self or others. That is a small subset of the mentally ill who are not really capable of self-decisions, or at least, that’s my impression.

#14

The danger posed to others from persons suffering some form of mental illness can present in diseases other than schizophrenia, and take place by means other than gun violence. Take, for instance, women suffering sever Post Partum Psychosis who hear voices telling them to kill their children.

And, as you say, these diseases can be (and often are), dynamic over time.

I posted this thread because it was alleged elsewhere that there is an ideology among some Americans, that there is an importance placed on individual Civil Liberties “that make it difficult to involuntarily commit a mentally ill person”, and because of this, those who espouse that position “share blame” when a mentally ill person commits an act of violence.

I have not accepted the truth of that theory. But if we were to, how would we resolve said dilemma?

#15

How many people are killed each year by the mentally ill as a result of their mental illness? Because as a society, we accept that 2500 people will die in traffic accidents; we accept that 2000 children will be victims of accidental drownings; we we accept that 40,000 people will die in traffic accidents. None of these things are good, but we don’t take them as evidence that there is something fundamentally wrong with the way we are dealing with fires, swimming pools, and driving. So I would be very leery of any attempt to limit people’s civil rights to solve a problem that doesn’t seem any worse --or any more solvable–than any of these others.

#16

Every so often on my way to work, I pass by this guy who walks about ten miles round trip to get a court-mandated haldol injection. He seems like a nice guy, but one can tell he’s lived a hard life. I don’t know the details of how he entered the “system”, but I imagine they involved some violence or self-harm.

#17

You are focusing on a different issue than the one raised by the OP. I agree that how people engage in mental health services, willingly or unwillingly, is important, and will have a great deal of influence on the course of their lives and their ability to be successful and to maximize their quality of life.

However, when you focus on people living on the street, you are again narrowing the band within the spectrum of people with mental illness to be over-representative of people with schizophrenia. Furthermore, the type of violence that the OP is concerned about is qualitatively different. Yes, mentally ill people living on the street engage in more violence than other mentally ill people, but that’s because living on the street engenders violence, and that violence often serves a functional purpose for those individuals, in terms of protecting whatever stuff or territory they would prefer to keep, defending themselves, and so forth.

The type of violence that I believe was the focus of the OP were acts like the shooting in Arizona. Obviously, the perpetrator there was not living on the street. Nor was the guy at Virginia Tech. If we want to concern ourselves with homicides associated with low SES conditions more generally, that would be awesome, but Brian Williams is going to have to bust his ass doing all those Nightly News remotes – in terms of firearms homicides in the US, we average around 15,000 a year or so, last I checked.

Conversely, if we want to focus on preventing mass murder by people with schizophrenia, then we can use the same purple ribbon I have on my porch that prevents bears from attacking my home. I promise you, if you put one up anywhere in your house, the number of mass murders by people with schizophrenia in every year thereafter will be essentially zero.

This will be especially intrusive if you want to include not only preventing violence, but also preventing decisions that lead to a downward treadmill towards lower SES and undesirable life outcomes.

I think that our society has an exceptionally poor social net, making it difficult for people with mental illness to willingly or voluntarily avail themselves of sufficient resources (speaking more broadly here than even mental health services alone). I can’t see any way to increase the degree to which we can force people to avail themselves of such resources, outside of actions taken to prevent other people from harm associated with the potential risk presented by a specific person.

#18

You raise a good point. Because AFAICT we have two legal or quasi-legal definitions of “insane” in the US. One is the M’Naghten rule, and the other is the one used to decide if the person can be involuntarily committed - does he present an immediate danger to himself or others? (Maeglin in another thread has linked to the AZ law used in the second circumstance, so states vary.)

It has not been determined whether the AZ shooter (assuming his guilt for the moment) is crazy in either sense. Clinically, perhaps; in the popular sense, no doubt, if you can base such a diagnosis on YouTube videos.

Nor can I. It’s hard for me to believe that Loughner would voluntarily avail himself of mental health services, and therefore the discussion turns, as it must, to what we can do to him, or for him, against his will. And especially, before the fact - what can we force him to do when he has not been convicted of a crime?

Regards,
Shodan

#19

No. He/She refers you to a psychiatrist for your routine mental health checkup. Maybe they catch slipping mental function and suggest certain types of activities to keep your brain sharp. Maybe they notice a slight bit of depression and recommend a regular exercise routine. Maybe they say see you again in 3 or 4 years. Maybe they do a deeper evaluation and suggest temporary commitment because you have some serious problems. I never said anything about involuntary commitment. I suggested a small step to make evaluations wider spread and more socially acceptable.

#20

We don’t even handle cooperative mental patients well in some cases.

John Hyde, and Albuquerque mental patient, had been actively seeking the attention of his care providers for about a week before he murdered 5 people. In at least one case, a hospital had him removed by security because they felt he presented a danger to staff and other patients.

http://www.msnbc.msn.com/id/18127174/ns/dateline_nbc/