So. Last spring I heard a public health wallah on NPR talk about the fact that there is no intermediate step between involuntary institutionalization and voluntary therapy. That is, the government can’t mandate any sort of mental health care other than by essentially incarcerating the moderately unstable. This is bad.
The suggestion was that the courts (presumably the courts, since that’s who ultimately makes the decision for involuntary institutionalization) should have the ability to compel a person who has committed no crime and who is not currently considered to be dangerous to check in weekly with a probation officer. Well, not technically a probation officer, but a therapist or perhaps social worker or someone who will keep that person under observation. Then, if that person goes, as the parlance has it, off his meds, either literally or figuratively, the officer would have the responsibility and authority to put him away.
The odd thing is that no matter how I slant the language, it still seems to me like a good idea. Oh, there are lots of problems with it, I am aware of that, both from a constitutional and a medical perspective. But look—you’ve got a Joe who is brought to the attention of the courts as being potentially in need of involuntary care. They investigate, however that’s done, and they essentially say to themselves Joe is not about to snap, so it would be wrong to lock him up. So they don’t. There is a court record of this, but there’s no way to know whether, six months later, Joe has started drinking heavily, or Joe has been visiting gun shows out of state, or Joe hasn’t left his room for a week. Or, for that matter, whether the combination of therapy and drugs that Joe was responding to has now failed, because Joe has stopped taking the drugs (or can’t afford them) or stopped going to therapy (or his insurance made him change therapists) or for whatever reasons.
On the other hand, for every Joe that you are able to catch in such a system before he commits some violent act (perhaps against himself), there are thousands of Joes who you will be putting on probation (essentially), who have committed no crime. Futhermore, since all of those Joes have their liberty at the whim of their probation officer, the potential for abuse is substantial, particularly since these are very vulnerable Joes in the first place. Even well-meaning well-trained court observers would likely make it difficult for a Joe to change therapy or medication, even where the change should be well within Joe’s rights. And there will be observers (as with the state social workers) who are either ill-trained, corrupt, burnt-out, overworked or incompetent. So it’s pretty well certain that if this system were in place, there would be a fair number of cases where the government would be actively violating the rights of innocent citizens. Citizens with mild mental illnesses, to whatever extent that changes things.
Back on the first hand, that violation would need to be balanced by the violence that this sort of program would diminish. I don’t mean to say that any particular act would have been prevented or could have been prevented by such a program, just that there are (as I understand it) a fair number of assaults, murders and suicides that are committed by people who were at one point marked as unstable and who had in the weeks before committing violent crime been thought by acquaintances to have become increasingly unstable.
Back on the other hand, though, that’s presumably a small percentage of crime in this country and an expensive program to combat it; if we were going to spend a ton of money on either mental health or crime prevention, there are other underfunded programs.
It would be easier if someone were to explain to me how the entire idea is awful and wouldn’t work, and there’s no need to do the difficult ethical calculus. And no, there really isn’t any need to do that calculus anyway, because there is no real chance of such a program actually being put in place in the next couple of decades, anyway. But still.
Tolerabimus quod tolerare debemus,
-Vardibidian.
The entire idea is awful and wouldn’t work because innocent flakiness would be mistaken for criminal behavior, and innocent flakiness is often a side-effect of mental illness.
So much for “people are different one to another, and that’s what makes the world interesting and fun.”
Please read The Loony Bin Trip by Kate Millett.
I’m afraid I don’t have enough detail to really get either of your objections. Specifically, how do your objections make the current system better than the one I’m imagining?
To make it clear, I wouldn’t allow the court to mandate any particular method of care, or to mandate any care at all, absent a criminal conviction. I wouldn’t make it any easier to institutionalize a person against their will than it currently is. I would allow a court, when presented with a petition to have somebody locked up, to have the petition denied pending an observation period, during which the person would have full liberty but be compelled to report in once a week (or whatever, I have no idea whether every other week or once a month would be enough). That’s the proposal. Is my assessment of how that would damage the innocent flake or the whatever-Ms.-Millett-is-writing-about that low? If it is, how? I don’t mean to be challenging in any oppositional way; I have little direct experience with the mental/industrial complex.
Thanks,
-V.
Hmm. After what could only be called a night’s sleep in some sort of ironic jest, I find I have a new objection to the NPR-wallah’s proposal, which may actually be what y’all are on about.
In the current system, the judge has only two options, so there is a substantial incentive to simply say that Joe doesn’t need to be committed, and end it at that. In my imaginary system, the judge would presumably have almost no incentive to take that option, because if Joe’s family (or whoever) brings a petition to a judge, the easiest thing will be to put Joe into the observational program for six months. And then, presumably, the easiest thing for the observer will be to recommend keeping Joe in the system for another six months, and so nobody will ever get out of it. An exaggeration, but that would be where the incentives sit.
Further, with this option, it may be that Joe’s brother (or whoever) would be more likely to bring a petition to have him committed, because after all, the likeliest thing is just observation, and so it’s not that big a deal. At present, presumably, there is a lot of reluctance to have a family member involuntarily committed, but this would be a sort of easy entry into the mental/court system.
Furthermore, it’s hard for me to see how the incentives could be weighted the other way. I mean, there are lots of potential problems that could be explained away by saying that we get really good observers, or that we tighten up this or that rule, but I can’t yet think of a way to make the system useful without making it useless, if you know what I mean. A maximum observation time of a year or even five years seems like a good idea, but then those may be the people who really need observation. So.
Now, I just need somebody to tell me why it really is worth looking at further.
Thanks,
-V.
You seem to be settling for the “nay” side in your followup comments, so I don’t want to pile on. And I guess it makes for a tiresome argument if you are saying “it’s bad that it’s difficult for the government to mandate mental health care” and my response is “No it isn’t!” But I found this proposal horrifying, and as someone who very much hopes that socialists and libertarians can work together effectively in the Democratic Party, I could probably use the practice at making effective arguments against the worst offenses to liberty, so here goes: a person cannot “have full liberty but be compelled to report in once a month (or week)”. Especially not if they are reporting to someone with legal power over them, in order to pass a lifestyle test! Yes, we do sometimes make some people report in and pass a test if they’re going to engage in certain high-stakes sorts of affairs – practicing medicine, driving cars, etc – and despite my libertarian leanings I am more or less okay with that, it seems to work pretty well in practice. The observation nation is a system where a certain subclass of people (potentially anyone whose lifestyle seems “unhealthy” to someone in power) have to get a license *just to live their lives* and then renew it every month (or week). This seems like a good idea exactly as far as one thinks systematic persecution of any non-criminal group is a good idea. And we’re the Democrats: we’re the champions of strong civil rights. This is not an idea that belongs in our party.
add it to the list of public-health-preventions-that-need-funding. then see how the crime rate changes. then consider it. NOT before.
i knew a person who went off his meds. he lived across the hall from me for four years. his weekly nurse visits ran out. he died. “the body” was “found.”
it #1 referred generally to covering mental health, including home visits and family support. it #2, i think, would only come to pass if it #1 were pursued as the traditional promise-but-do-not-finance backstab. this kind of stuff is exactly what you would expect from a system that socializes only the greatest risk — a panicked answer to a poorly-constructed question.
Again, the suggested system would not make it easier for the government to mandate mental health care at all, in any way. Which isn’t to say it’s a good system, but that if the objection is to government mandated mental health care, it’s not an objection to the system. It’s not as clear to me as it seems to be to many of you that so many people’s families would be so anxious to have them committed, but then there’s no reason to think that my instincts on that are right, and y’all’s wrong.
I do have to ask all of you who objected: are you against the government having the authority to commit people to institutions at all, under any circumstances? How would you change the current system, if you think there it’s too easy to mandate such care? Do you think that there’s no problem with our current system? I’m perplexed.
I do think that hapa’s right (as I suggested in the first place) that a ton of money for mental health would be better spent in other ways, although it’s not clear that there’s any real opportunity to do that in the near future. We’re failing people like hapa’s neighbor in a gazillion ways; the proposal I was talking about was meant to address one of them, and I think it does do that, and even if (as it seems), it isn’t a good system, taken all in all, it does seem like we should be kicking around various proposals that have some chance of being enacted.
Thanks,
-V.
Right, well, this may not be terribly surprising to anyone who’s read a few of my posts, but in 1996, I was (incorrectly) diagnosed as bipolar type something-or-other. The kind with psychotic episodes. I was stuck in a hospital for ~ a month and then released under medication. I “went off my meds,” frequently, and I “missed appointments with my psychiatrist” rather less frequently, but frequently enough that if someone had decided I was a danger, I would have been flagged as a danger.
To be clear: I was not a danger. I was a sad, pathetic stoner who couldn’t get his act together to buy meds that cost $100 a month, but who could instead scrape together the money for a bag; and who couldn’t remember that his appointment was this afternoon, ’cause I was napping or high. Under the proposed system, I would have been “put away,” especially when it was found that I was “in possession.”
It ultimately turned out that although I do have more-manic-than-normal episodes, I don’t really have the depressive cycles, and I only go into psychosis with the application of extreme sleep deprivation or psychedelic chemicals. Working through all the psychiatrists and all the social workers to get to that understanding of how my brain chemistry works took the better part of a decade.
Psychiatrists are in the dark when it comes to diagnosing mental problems. Sometimes, it’s cut and dried. A schizophrenic pretty much looks like a schizophrenic. But what does one do with a manic stoner? With a heroin addict who has panic attacks? What does one do with the vast number of “schizo-affective” people, where “schizo-affective” is a psychiatric variable containing the value “I have no fucking idea what’s wrong with this kid?” Psychiatrists throw meds at disorders and hope they stick, but they have no idea what any given chemical is going to do to any given brain. More idea than you or I, perhaps, but that idea of theirs, I assure you, is not a very specific one. Geodon? Depacote? Zyprexa? Haldol? Well, none of those are working, let’s try Trilafon. Furthermore, meds frequently stop working. Some meds, for instance, alter the chemistry of the brain after they’ve been there long enough, and then the brain chemistry is imbalanced again, so the patient gets switched to another pill.
Big pharma, incidentally, loves this. Insurance companies, however, hesitate to under-write such patients, so unless they get covered by an employer, it can be hard for a patient to get inexpensive health insurance. Certainly, the pills aren’t inexpensive. Also, it can be difficult for such a patient to get a job, or to hold one. Going off meds? Pretty effin’ frequently, thanks.
Anyway, I am now a sober, responsible father, and I’m a productive member of mainstream society. I doubt I would be, if I had been shunted into the criminal system twelve years ago. I certainly wasn’t a criminal (beyond the banal criminality of smoking weed) or a threat.
Could such a system have prevented the Tech shooting, specifically, or the Illinois shooting? How often do the ill need to check in? How long had Kazmierczak been off his meds? How long would he have had to have been off them to show signs of being erratic? Would his social worker had recognized the erratic behavior as a symptom of being off his meds? Would the social worker have done anything? None of his friends did.
A system that might have prevented either of these shootings would be to have psychiatric “red flags” allowed in background checks when otherwise legally purchasing a gun. *
My philosophy is always in favor of individual liberty, because any other system is A) oppressive and B) self-delusion. No system could have prevented all of the mass killings in the news lately, but such a system as you propose could have kept me from meeting my wife and being a sane enough person with a good enough position in life to provide for my child.
peace
Matt
* (Why is it that the second amendment trumps human rights? “Well, damn, Zeke, lookee there! You sure blew that squirrel up pert’ good! Pass me a Bud and the box o’ bullets, will ya? Figure we got time for a few rounds ‘fore church? Maybe we can fire a couple blanks at ol’ Crazy Matt, watch him wet his pants! HAW!” And another thing: Why is claiming to talk to Eris crazy, but claiming to talk to Jesus is sane?)
Hmmm. So what you’re saying is that you fell through the cracks of the system, which was the best thing that could have happened to you, and that therefore attempts to stop up the cracks would be detrimental. That does sound plausible.
The people I know personally who have spent time in hospitals for psychiatric care have all done so voluntarily, for various definitions of voluntarily that may not involve volition but don’t involve court orders. So I haven’t been extrapolating from their stories. But then, I don’t have much else to extrapolate from, either.
Another problem I have with the entire issue is that while it is true that psychiatrists are largely working blind on brain and mind issues, they are also doing fairly well doing it; I know lots of people who, while struggling with the pharmaceutical/psychiatric complex, have achieved a sort of stability, not to say functionality, not to say happiness. These stories are not simple found-the-right-pill stories, but they are successes. There are also lots of rather horrible stories of failures. I would like to encourage our actual system to, you know, tend to more successes and fewer failures.
The basic answers are not likely to occur in the short term, either comprehensive and secure health care or societal reforms, and although that certainly does not mean we should stop working for them, it does mean (to me, at any rate) that work should also be put into short term ameliorations. So. I’ll happily give up on this one, because y’all have convinced me that it wouldn’t actually ameliorate, so that’s all right. But I still like to kick stuff around.
Thanks,
-V.
P.S. Not sure about talking to Jesus, but I don’t think that anybody ever called Ezekiel sane.
Quite. And it’s not actually that I fell through the cracks, entirely, or even ultimately. By the time I met Nancy, I was In The System, and the system I was in was in fact stabilizing. However, I would have fallen through the system you described above, and I suspect (given my attitude at the time towards
fascist, goose-stepping toadies to the Manpolice officers, as well as the law’s position vis a vis my lifestyle) that I would have fallen through it hard.peace
Matt
PS And actually, it’s not talking to Jesus that’s crazy, or even talking to Eris, although that unfairly gets one funny looks more frequently, it’s Jesus (or Eris) talking back that concerns me…
Huh. If you could check my HTML, there’s supposed to be a strikethrough tag around “fascist, goose-stepping toadies to the Man.” It may not be funny that way, either, but it is what I was trying to post…
peace
Matt
> Again, the suggested system would not make it easier for the government to mandate mental health care at all, in any way.
I’m not sure what you mean here. Isn’t the whole point that if you think I should be compelled to obtain mental health care, right now your only option is to wait until I commit a crime, and then have me sentenced to spend time in mental health jail, which you obviously can’t do unless I actually commit a crime; but in this new system, if I am judged to be sufficiently crazy, you can have me sentenced to see a mental health probation officer (and compelled to continue doing so indefinitely)?
That sounds like government mandated mental health care; and it sounds like it’s easier for the government to mandate than it is now, because you don’t have to convict me of a crime, you just have to convince a judge that I’m crazy.
There are two systems, one for people convicted of crimes (more or less, for different definitions of convicted in different states), and one for people who haven’t. The rules differ state to state, but generally, the state can commit people who it judges to be a danger to themselves or others due to mental illness. The rules for this differ from state to state; I have no idea if this chart is accurate, but it’s got citations with the little legal symbol, so it looks good.
Finding that chart, I found that many states do have a process for involuntary outpatient treatment, which strikes me as a bad idea, worse that the idea I was originally discussing, having all of its flaws as well as the flaws that (I think) people assumed it had but (I think) it didn’t. Neither my own state nor yours has such a law (unless the chart is wrong), but look out Virginia.
I am distinguishing, and I think this is important, between my observer/probation officer and treatment; the observer could not prescribe medication, nor would it be his job to administer talk therapy. The observer would look for obvious evidence of drug use (sorry, Matt), black eyes and the like, and of course refusal to show up for the session, and likely other things, presumably in a short conversation. It would obviously be a difficult line between the privacy rights of the individual (which still exist, even though diminished by the court order in ways that would have to be narrowly defined) and the usefulness of the observation, but it doesn’t seem impossible to design. And no, it wouldn’t “catch” everybody, but it would go some way to stop up the cracks, which at the moment are more like canyons.
Which isn’t to say it’s a good idea; I’m convinced, Gentle Readers, that it is not, so thank you for that. But I wanted to clear up what was a bad idea, because, you know, it seemed important.
And I’m not sure why strike isn’t working in my css; I’d pester my Gracious Host about it, but he’s got other computer problems right now.
Thanks,
-V.
To Do
deal with strikethroughThanks,
-V.
Well, and my drug use was the problem, so it would be nice (now) if I had stopped it earlier. But, and I think this is important, it was my decision to stop, when I stopped, and I was able to reacquire responsibility and respectability. If my case worker had decided (incorrectly) that I was dangerous, and if I’d been moved from the mental health system to the criminal system, I doubt that I would be responsible and respectable today.
Personal change is not something that can be mandated by outside forces.
Anyway, it feels like I’m still trying to convince someone that the proposed system Would Be Bad, and V has (twice, at least) asserted that he’s convinced, so I don’t know why I’m typing, anymore.
Except to say that there’s no reason to be sorry for our nation’s benighted attitudes, nor yet for my state’s benighted laws, for instance.
peace
Matt
Yeah, I have some sense that I’m responsible for defending the idea, despite having been convinced that it’s a bad idea. Which is strange, since the whole point of the post in the first place was that I wanted to be convinced it was a bad idea, and I was, so shouldn’t we all be happy?
However, looking back at the beginning of the post, I did write that the issue was that the government can’t mandate any sort of mental health care. Re-reading it has eased a lot of my frustration that people for some reason persisted on thinking I was talking about government-mandated mental health care. Oops. My fault. And I suspect, thinking back on the radio show from way back when, that the fellow was, in fact, talking about government-mandated mental health care, and that when I translated that to an actual policy program, I changed it from something that I wouldn’t seriously think about supporting to something that I was having trouble articulating why the balance tipped against it. So, my confusion, and presumably other people’s confusion as well.
You know, if the Giants weren’t so unimaginably bad, I’d be writing about Spring Training. I blame Brian Sabean.
Thanks,
-V.
Dude, didn’t they win the Superbowl? How could they be bad already?
peace
Matt
What’s a superbowl?
-V.
I think it’s what makes life interesting and fun, but that could be NASCAR…
peace
Matt