Questions on Institutionalization

Great Debates
61

No. None.

“Paranoid schizophrenic” may “mean nothing” to you, but for most it is a generally-understood way to convey a significant amount of information with a few words. It is a label – using the word not in a pejorative sense, but in a literal sense – and it serves the same purpose a label does in any other situation. You may refuse to accept any of the information intended to be conveyed because to you the label “means nothing,” but to me that’s nothing more than willful obtuseness on your part. I don’t feel constrained to refrain from using useful labels or shorthand because you declare that IYO they are meaningless.

Why would you assume that criminal behavior meant the police were automatically involved? There are actually people in the world who will overlook a certain degree of technically criminal behavior if they know the person in question is mentally ill and they believe the behaviors will be addressed short of criminal charges. This man was occasionally physically assaultive to his mother (shoving her, hitting her). She would never have dreamed of having him charged. He make people feel unsafe by screaming at them and approaching them in an apparently aggressive matter. I suppose it would have been technically possible to wait until he actually assaulted someone, or was beaten up again, but I fail to see how that would have improved his situation any.

I’m sure I don’t know. I do know that it was the only available home for him. It’s not like there was a nice long menu of potential placements for the guy, of which naturally he would embrace “the healthiest.” There was no place else for the guy to go. He was too ill for community placement, even closely supervised – believe me, they tried that, repeatedly. He could live with his mother, who barely could care for herself, much less him; he could be homeless, and at extremely high risk of being victimized; or he could be placed in an institution. There were no other options. Even if in-community placement had been appropriate for him, which it wasn’t, there are long waiting lists for those beds. Where should the guy go in the meantime?

Trashing an apartment, scaring the neighbors, or not paying the rent, are none of them automatically criminal behaviors, so I find it interesting you assume police involvement. The landlords didn’t involve the police, they just evicted the guy. Then he wasn’t just acutely mentally ill, he was acutely mentally ill and homeless, until his mom broke down (again) and took him back in (again). I also am interested in your implicit reliance on “the police” or the bringing of criminal charges. In those cases – also very common – the person ends up in the local jail. And if you think the mental health services offered in local jails is better than that offered in hospitals through involuntary civil commitments, allow me to bitterly laugh.

He had SSDI. He spent it on alcohol, DVDs, bus trips, and sponging friends rather than, say, food. He did not have the capacity to manage money, his thoughts were generally not ordered enough. His mother had his SSDI and used it on his behalf, which only led to more fights and physical threats to her when he demanded she give him “his” check.

What is the distinction you are drawing between a “psychiatric group home” and an institution? Assuming the “group home” is for persons who are severely disabled enough to require locking them in so they don’t escape – what meaningful distinction between that and an institution are you drawing? And what does that have to do with involuntary commitment? Even if you are committed to a “psychiatric group home” instead of a hospital, you’ve still be involuntarily committed, right?

It was NOT a group home situation. He had been in several group homes, and the placement had not worked. He was aggressive and assaultive to the other residents and staff. He could not or would not meet the minimal requirements to live in a group home.

[quote]
What about the American equivalent of extended leave provisions? I believe you call it “assisted (or assertive) community treatment” or some such. In that case, being non-compliant isn’t an option if you want to stay out of the hospital.[/qutoe]

YES. If you want to stay out of the hospital, you have to be complaint. If you are not, you go back to the hospital, where the process of making you stay there is involuntary commitment. That was this guy’s situation. So was hospitalizing him appropriate, or not? Any such hospitalization would be involuntary, because he lacked the mental capacity to make such decisions.

He WAS treated like a human being. And his preference was that he get an apartment (which he couldn’t do) and a job (couldn’t do that either) and be left alone.

You can hardly expect me or anyone else to agree with you that it better to be homeless and at risk for victimization than it is to be hospitalized and receive treatment. You are entitled to your opinion, of course, but the value of it is to me pretty self-evident.

Did you have a substantive response to my point, which is that they have no more ability to care for themselves than a baby does, or would you prefer to simply take issue with the word choice by inferring a “comparison” where one wasn’t made?

I’m not really interestesd in arguing with your opinion beyond reiterating that it doesn’t tally with my experience in any way.

Sure, I pardon you. You are generalizing from your experience, which is fair. But I can only convey my own. The difference between us is that I am not insisting that your experience must have been wrong just because it happens to be different from mine. The system didnn’t work for you. That doesn’t mean it never works; in my experience, it did. Nothing you can say will change the reality of that.

62

EDIT [to late to add to post: If you do indeed mean “right now”, I would empanel some kind of officials and formalize some evaluative standards.

• Who are you? Can you tell me your name? Your current address?
• Do you know where you are? What city, what country etc?
• What year is this? What month? Do you know today’s date?
• If you accidentally ENDED UP in some city that you’ve never been in, where you do not know anyone, what would you do? How would you get home (if not directly addressed by ‘what would you do’)?
• Do you know WHY you are here? IF NOT ADDRESSED BY THE ANSWER: There is some concern that you are not able to take care of yourself right at the moment. This is an emergency temporary competency hearing. Do you understand what that means?

I’d standardize the range of answers that indicate “this person cannot be held involuntarily” versus “this person should be held over for 72 hours”.

The beforementioned officials would be on shift; someone would always be available to conduct the exam 24 x 7.

63

No. It’s my hypothetical, so you’ll have to deal with the most extreme case because that’s what I’m presenting. It is incontrovertable that this person is gravely disabled. You agree, I agree, everyone agrees. He or she cannot care for him- or herself – not an opinion or a belief, a fact in this scenario. These are the facts of this hypothetical, so you are not in a position to dial it back to one person’s opinion. Even if you want to cast it in terms of opinion instead of fact, you may deem the opinion to be absolutely universally held, including by you.

Yes. RIGHT NOW. He wants to leave, and he is incapacitated. What do you do RIGHT NOW?

Of course it does. You have to convene the hearing, which is going to take some amount of time; what do you do in the meantime, what do you do NOW? Because if you don’t let him leave, you are holding him involuntarily.

I am asking you what you do RIGHT NOW when you are faced with an incapacitated person who is insisting on leaving. Your concern seems to be the involuntary nature of any commitment, none being IYO okay, as far as I can see. So do you let the guy go, or not? Because if you don’t, you have involuntarily committed him. The only question then is how quickly you can hold a hearing to determine whether or not that action was justifiable.

64

Pardon me, but the important difference, it seems to me, is that as long as there are more than a vanishingly small quantity of people having experiences such as those that G Pie is describing, your well-intentioned but involuntarily imposed “help” is doing damage and is infringing on people’s civil liberties; and insofar as it is doing so, it disenfranchises EVERYONE since it means NO ONE is safe from it happening to them as well.

SOME people who would benefit from imposed help will therefore go without, because it is by far the lesser of two evils to err on the side of assuming folks are entitled to self-determination until proven incompetent to exercise it in a venue and under standards that set a rigorously high bar for proof thereof, rather than on the side of assuming that if it appears someone needs help that they do not consider themselves to need, it’s probably because the help that they have not as of yet received makes them incapable of realizing they need it.

65

No no no. You don’t have time to “empanel some kind of officials.” Even if one already exists, it takes some amount of time to reach them, get them to come in or fax them the necessary information, whatever. The guy wants to leave NOW. Do you let him go or not?

Oh, I see. We are theorizing the utopia of mental health services, with unlimited money. Suffice it to say that does not reflect the reality of a system in crisis, where mental health services are being reduced or eliminated in every jurisdiction, and the idea of “officials continuously on shift” and “someone always availalbe to conduct the exam 24 x 7” is pretty much the definition of a pipe dream.

66

No it’s not. Even if I agree, you agree, everyone (except the allegedly gravely disabled person) agrees, we may all be wrong and the person at the center of this matter may be right. That person is entitled to SOME kind of safeguard, even if it, too, is not going to be an infallible mechanism.

We’re posting past each other in a flurry of posts, aren’t we? Post #62, above. And

Make it part of the police force. THEY manage to exist 24 x 7. Pro forma questions, pro forma eval of answers given. Quick test to qualify to perform the test, required of all police officers. Done.

67

How does it disenfrancise EVERYONE even if I were to grant everyone is at risk, which I do not? Disenfranchisement is the deprivation of your personal liberty, not merely the risk thereof. I am by no means convinced the wrongly involuntarily civilly committed are in fact anything other than “a vanishingly small quantity.” Even if so, the cost-benefit analysis would be the number of people who are assisted through the system versus the number upon whom the system works an injustice. I strongly disagree that the mere potential of injustice for some extremely small subset means we just stop trying to help anyone by chucking the system out. No system of justice is perfect or works perfectly in every case.

You continue to import an element of an ASSUMPTION of incompetency that is not in reality a feature of the process, much as you seem to want to insist that it is.

68

Bullshit. Your schizophrenia is not based on any doctor’s opinion, it is a diagnosis based on very specific criteria. Here, I’ll elaborate:

If you are hearing voices or seeing visions that cannot be detected by other people’s direct observation, by definition that’s a halluciation. How tricky is that? Keep in mind, if you really ARE receiving secret messages from the government beamed directly into your brain, then the burden of proof lies on you to demonstrate that it’s really happening, and not a symptom of brain malfunction.

Isn’t that the point, though? The exact neurochemical effect is irrelevant to whether or not the medication is successful at alleviating symptoms.

No argument there. But the whole point of involuntary institutionalization is to aid people who no longer possess the ability to help themselves. Whether or not mentally diseased individuals possess that ability under typical, everyday circumstances is not germane to this thread.

69

If the United States of America can detail any individual as a “possible terrorist” and hold them indefinitely without any specific charges, with no guarantee of a day in court, WE ALL have had our civil liberties eroded. The universal guarantees of due process and so forth have been eroded FOR ALL OF US. You have heard those debates during the timeframe following 9/11/09, yes?

Same deal here.

70

This makes me really impatient. This is a HYPOTHETICAL. It is MY hypothetical. I am telling you the conditions of this fictional scenario, because I SET THEM. Therefore you have no basis to tell me those conditions are wrong, unless you just don’t understand how a hypothetical scenario works. You seem to be working awfully hard to avoid answering the question, which is fine, I guess, but I’m not going to chase you around for a straight answer any further.

The person HAS safeguards. That’s the whole point of the involuntary commitment hearing; that’s that it is: A procedural safeguard against wrongful commitment.

Actually, this is occurring in some locations, through the use of CIT (Crisis Intervention Teams) in cities including Memphis, Salt Lake City, and Raleigh. These teams are made up of specially trained police officers, mental health professionals, and social services representatives. They are intended to prevent mentally ill persons from being taken to jail, essentially as a pre-arrest diversion program. The issue is that such programs tend to be expensive and it’s too early in the process to determine their usefulness versus their cost. And you continue to interpose steps that may not necessarily change where things end up: Even if the police or CIT do the initial evaluation, as you suggest, a person who is severely decompensated is still likely to be taken to the hospital and involuntarily committed, in the absence of any better feasible alternative.

71

You seem to be conflating “erosion” and “disenfranchisement.” Even if I granted that, you have not addressed why the potential of injustice to the very few justifies doing away with a system that provides help and safety to many who need it.

72

  • delusions <—— you can’t describe one single thought that might be in my head and identify it as a delusion or as non-delusional thinking. All you can hold is a perspective or an opinion on the subject.

  • hallucinations <—— likewise

  • disorganized speech (e.g., frequent derailment or incoherence) <—— means merely that you, hearing the speech, are not following it. Your inability to do so MAY be attributed to the incoherent nature of the speech but it MAY be due to your inability to follow it due to you lacking the necessary background, contextual clues, empathy, etc to follow a conversation that someone else might make sense out of without great difficulty. And you cannot KNOW WHICH is the case.

  • grossly disorganized or catatonic behavior <—— catatonic is markedly less open to interpretation, although even there context plays a major role. You can’t assess whether someone is catatonic in a hostile environment from which a rational but upset person would wish to withdraw, for example. That sort of rules out making that assessment in a locked ward environment. Grossly disorganized, like the others above, is far from objective and depends on YOUR notion of organized which is not necessarily intrinsic to the behavior you are interpreting but may have more to do with the limitations of your interpretive acumen.

  • negative symptoms, i.e., affective flattening, alogia, or avolitio <—— and once again, massively subject to contextual interp. Flattened affect is normative under threatening or stressful conditions, all the more so when someone is apparently medicalizing and psychiatrizing your every behavior and your every expression of anything you do feel. And where any passionate outburst is going to bring a sharp needle your way.

73

So what? Opinions and beliefs are important. Even the laws of Newtonian physics are essentially based on a series of approximations.

Shame on you for attempting to equate medical treatment with the travesties of Guantanamo Bay. Those so-called “enemy combatants” have been held captive in prison for YEARS without due process of law, and have been subject to unjust torture which violates international convention. There can be no comparison drawn between that situation and involuntary commitment, which follows carefully crafted guidelines and is only invoked under extraordinary circumstances.

If you have evidence that these guidelines are being violated on a routine basis, go right ahead and present it. But I suspect such evidence does not exist. :rolleyes:

74

And I want to be very clear: I am by no means saying the system is perfect and there is no room for improvement. But the mentally ill are a marginalized population in US society (as in most societies), the most marginalized are those at the extreme edges of that class who (a) are severely mentally ill, and I mean severely, and (b) have few, if any support structures or resources available to them. Those few tend to fall on the mercies of the public health system, which is overburdened and stretched to the breaking point in all areas, but especially in the area of mental health. Given the lack of resources (and resources were dwindling even before the economy went south) those mercies are not as tender as one could hope – especially if one is unfortunately a consumer. But we do the best we can with what we have, and if it doesn’t work perfectly for everyone, that doesn’t mean it doesn’t work at all. I am happy to entertain suggestions for system improvement, but would only point out that at this point NO ONE has any money to make any such improvements, it’s all they can do to keep the old, flawed system limping along.

75

I had a neighbor who worked at Tinley Park Mental Health Center in suburban Chicago and she said it was virtually impossible to detain anyone against their will, unless they admitted they were a danger to others or themselves. And even then it’s just a temporary hold of a few days where the hospital has to go to court and get a court order to hold them, even IF they say they will harm others or themselves.

Despite what you see on TV, those shrinks aren’t idiots, they give a battery of tests that are specifically designed to trip people up, at least trip people who are faking it.

They’ll ask the same question in ten different way and you need to produce the same answer ten times or else you’re sane.

At state mental hospitals they are keen to try to get rid of the substance abusers and old people with demntia if at all possible, because they are simply out of the scope of the hospital’s purpose. A junkie may have hullucinations like a mentally ill person but the junkie’s visions are 'caused by outside influences.

76

I had something a bit more stripped-down in mind than what you’re referring to, I think.

Police Officer Joe Friday receives 3 hours in training, training consisting of “You ask these questions. Here is a multiple choice exam consisting of hypothetical answers given to the questions, and you pick which answers mean ‘competent person’ and which ones do not. Aah, you did good, you recognize ‘competent’ and ‘incompetent’ answers when given.”

Any time a person is thought to lack capacity to make their own decisions and current situation is an emergency basis such as our hypothetical “into-traffic-walking person”, Joe Friday is dispatched, asks The Questions, doesn’t try to make any really deep evaluations requiring insights of his own just evals the answers as he was trained. Just the facts, ma’am: your patient knows who he is, where he is, would not or could not give a coherent answer about when it is, could not explain what he’d do if he got on the wrong bus and ended up in a strange town, and could not give an intelligible answer to what an emergency competency hearing is. Yeah, doc, you can hold him 72 hours.

You now have 72 hours in which to get this onto the docket. This person’s civil rights are no more jeopardized by being held between now and then than if an arrest had been made for an alleged violation of the law. Police DO get to arrest you without proving right then and there in a court of law that yes you did commit the crime. So I am fine with this. You don’t have to get this person up in front of the judge for the hearing ITSELF within 72 hours (getting it on the schedule would be sufficient) but there should be some kind of equivalent of a ‘bail hearing’ with a more formal assessment of whether the person in question is really at such serious and significant and immediate risk that they cannot be released between now and when the hearing takes place. Maybe again The Questions but with representation and the opportunity to provide additional information perhaps showing that the person in question has a stable environment in which they are liable to be kept out of trouble until the time of the actual hearing, etc?

Under my system they’d be found incompetent rather than involuntarily committed; THAT and not the commitment hearing, is what would take place 72 hours later. The incompetent person is no longer making his or her own medical decisions, whether they be psychiatric or cardiac or endocrinological in nature. The incompetent person is no longer making “where do I live” decisions either and may be held in a locked ward.

77

This discussion has moved into GD territory, so I’m moving the thread into GD territory.

78

I was wondering how the heck it was still in GQ!

79

The only difference between what you propose and what currently happens is that instead of a determination of whether or not a hold is warranted being made by a mental health professional and a doctor (or an MHP who is a doctor), as now happens, you propose to have that determination made by a police officer with three hours’ training. Hard to see that as an improvement in patients’ rights.

You’re just adding another hearing, which wouldn’t take place over the weekend anyway, any more that first appearance/probable cause/bail hearings take place over the weekend. So if the person is brought in on a Friday, it’s going to be 72 hours before the guy’s before the judge for the first time under your new system. That is the MAXIMUM time it can legally take before the due process hearing under the existing civil commitment statutes. So, again, I see no real improvement over the current system.

If they had a stable environment, they probably would not have been placed on a 72-hour hold in the first place.

I fail to see how this could possibly be an improvement on the existing system. As things are done now, a person who is stabilized within 72 hours is released. A person who is stabilized within 14 days is released. In both cases there are almost always conditions, like “keep your appointments with your case worker,” but there is no broader judicial determination of incompetency with all the legal baggage it would bring, such as being judicially stripped of your right to make your own medical decisions or your own personal decisions, without regard to whether or not you in reality can make those decisions. A judicial determination of legal incompetency has serious ramifications and can be difficult to reverse. A civil commitment doesn’t carry a finding of permanent incapacity; a finding of incompetency does. So your theoretical system would strip the individual of far more rights, and on a far more permanent basis, than the current system does.

80

So what I’m hearing here is that if 999 people are helped by involuntary treatment, then it’s just too damn bad if 1 person’s life is destroyed. How about 99 to 1? Still okay? What about 9 to 1? At what point would it concern you? How many harmless people are you willing to persecute in order that one dangerous crazy person gets forcibly drugged?