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Thursday, October 6. 2022
Many city people are asking that question. From a Psychiatric point of view, here are some of the difficulties:
First, prediction of dangerousness (like predictions of dangerousness to self) are notoriously unreliable. Only reliable after the fact.
Second, medical treatment without consent is typically illegal (assault, in fact) except in extreme circumstances.
Third, treatments for the chronically psychotic are commonly ineffective or only partially effective. Furthermore, many chronically-ill do not follow-up with treatments for a variety of reasons.
Fourth, perhaps the most dangerous category is Psychopathy which is a personality abnormality at its extremes. I doubt it is treatable, but it doesn't matter because these people lie and do not seek help anyway.
That's not to mention civil liberties.
There are other issues, but that's enough for now. AVI is an expert in the topic, so I hope he has something to add.
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I heard a comment on the radio the other day, not sure if precise, but sounds close enough.
In 1960's USA, over 1/2 million people we institutionalized.
More recently, number is less than 50,000.
I'm no expert, but this sure looks like an answer - YES!
How long do you think innocent people are going to put up with this?
It's a pity the insane cannot be productive in some way. They are useless eaters and the progressives will, of course, seek to cull ,otherwise.
European sanitariums in the olden times would try to monetize the insane. An example would be, selling the better paintings that the patients produce in art class.
The sanitarium could be a guild of sorts, that seeks out and encourages the productive strains in its captive population.
It is sad because you wouldn't treat an animal like that. Many people with mental health issues can be helped or at least made less dangerous to themselves and others through medication. If your dog could be made safer to others or made to suffer less with medication would you do it?
Here are some ideas that I'm sure the ACLU would reject:
If a person is arrested, detained or brought to the attention of the police for mental health issues to include drug or alcohol use that they must be given treatment. This could be 7-30 days in some form of confinement to treat their addiction and to assess them.
If a person who has mental health issues including drugs or alcoholism commits a crime they cannot avoid punishment by claiming mental illness and the must be sentenced to the maximum for the crime committed.
If a person who is mentally ill including a drug or alcohol addiction harms another person or property AND the mentally ill person was known to the police and courts but action wasn't taken then the victim can legally seek recourse from the city/county/state.
And last, anyone threatened by a mentally ill person can use deadly force without fear of criminal charges BECAUSE we know that mentally ill/addicted people are unpredictable and it would be unfair to the victim that they would have to endure an assault before they are able to defend themselves.
Is 'mandate' the right word? First you have to have a place to put them, for treatment. And if I read it correctly, I think Ronald Reagan is often tarred with being responsible for closing down the institutions wasn't he?
There should always be legal avenues for protecting people from self-harm or others from their deranged attacks, when they're mentally disturbed. But first there has to be a place to put them.
I used to think that. Then I saw the vaccine mandates. I do not trust the government.
Probably, but not without being put in institutions.
On a related note, I think it should be illegal to be homeless, and many homeless people are mentally insane. It would be more humane to put the insane homeless in institutions than what we currently do. Other homeless should be put in jail, or drug rehab, or expected to work or handed over to family who should be forced to take care of them, based on their conditions. All with due process of the courts and local/state governments.
All very common sense suggestions. I would add that avenues should be created to impeach and remove, through multiple ways, any judges who seek to prevent such laws from being enforced by state and local governments.
The problem is, even for violent offenders, if the violence can be traced back to mental illness, then the person often cannot be sent to prison. So they get locked up in psych, medicated, they get better... and then they get released back into the public where they go off their meds, stop seeing a doc, and start hurting people again. Wash, rinse, repeat.
I know this because my sister still has a bum hip and headaches years after getting KOed without warning by one such repeat offender, while on the job. The guy was twice her size and just suddenly decked her, right in the face. Hit her hip and skull on the tile floor when she went down, and it took three other employees to hold him down, so he'd stop kicking her. She hadn't even spoken to him. She never goes anywhere without a cane now, because stairs and other uneven surfaces are difficult.
That wasn't his first assault. He'd repeatedly beaten up his mother, who was supposed to be his caretaker when he wasn't in psych lockup. She wouldn't press charges because she was terrified of him. Another victim had been persuaded by the prosecutors' office not to press charges out of some BS compassion for the mentally ill, oh he's getting treatment now and it's OK blah blah blah. They tried that line on my sister too. She ain't buying it.
But hey, he's mentally ill. Can't put him in prison because he's non compos mentis or something. Can't keep him locked up in the state asylum because oh look isn't it wonderful how much he's gotten better on antipsychotics? Can't force medicate him once they let him go, because that'd be violating his civil rights or something.
What about the civil rights of the people he attacks? Do they have any?
A long time ago, I read an article written by a women whose brother was schizophrenic. Their family was very wealthy, so they had the means to do what was needed to take care of the young man. They loved him, so they had the desire to do what was needed to take care of the young man. But in many respects, their hands were tied.
He'd be on medication and do well. He'd be released getting the hospital. He'd come home to the family estate. He'd stop taking his medications and run away. They'd eventually find him, living on the streets of Manhattan. They'd bring him home and hospitalize him. Cycle would begin again. They'd hire nurses. The nurse or the family member would give him his medication and watch him take it. He'd spit it out or purge it later. They couldn't institutionalize him against his will for any length of time because he was not considered to be a danger to himself or others.
He froze to death on the streets of Manhattan.
Luckily, he was never violent. He never attacked anyone.
I read about another family trying to take care of their schizophrenic son. It was another family with the financial wherewithal to take care of him, and who loved their son. But it proved exceedingly difficult.
The most successful situation for him was living in a sort of halfway house on the grounds of the psychiatric hospital. The problem again was that as soon as he exhibited any sort of sense of "normalcy" he was no longer eligible to live there. He didn't want to leave. His family had the money to afford it. But he was doing better on medication, and "normalized" so he wasn't permitted to stay there.
He hated coming home and living with his parents, and would act out terribly there. He loved the sense of independence he got at the halfway house. And at the halfway house, his medications were monitored so he took them regularly. The family tried to set up something similar on their own: they found a rental unit near the hospital, hired some care workers, the mother frequently stayed there with him. But it wasn't nearly as successful. But it was better than any other options they explored.
Eventually, he, too, died young. It was related to a side effect of the medications. Apparently, they cause severe constipation. Extremely severe. So severe that normal OTC laxatives apparently aren't particularly helpful. I'm not sure why stronger laxatives weren't prescribed. He eventually "exploded" from it. This led to peritonitis and it was downhill from there.
I'm working off of my memory on these stories, so there may be some inaccuracies. But me recollection is that they both show how difficult the current system is to deal with mental illness even for families who care about their child and who can afford almost anything to help.
These issues are some of the most difficult a "civilised" society confronts.
I think we can all agree, however, that current approaches seem to have combined the worst aspects of several worlds.
In particular, the "off their meds" excuse makes me see red.
I've been binge-watching "Deadly Women" on my Roku lately. Sylvia Seegrist and Alyssa Bustamante both wound up murdering people, despite the fact that they were both known to be mentally and emotionally disturbed.
The whole "preventive detention" thing is a slippery slope, especially now that political Conservatives like us are slowly being stigmatized in a similar manner.
Why won't they take their meds? Because the anti-psychotic medication makes them feel like shit. They find the wild voices in their heads preferable to the dead, dull buzzing that keeps them from acting out.
Reagan is often blamed for it because the leftists need to find someone not a progressive/socialist to blame.
The reality is that it was a 'perfect storm' and had been brewing for over a decade.
- Mental institutions at the time were awful places to be. Lots and lots of abuse.
- Leftist crusaders asserting that it was a violation of the patients human rights to be involuntarily committed.
- New medications--SSRIs and anti-psychotics--that promised that "these people" could lead "normal" lives.
- Politicians wanting to cut budgets.
@JWM Because the anti-psychotic medication makes them feel like sh*t.
I didn't know that.
Now I feel the problem is even more intractable.
Why don't they take their meds? The meds do make them feel a little zombiefied but it is more than that. When taking their meds they no longer experience the craziness and are more "normal" and they begin to feel like they don't need medications so they stop taking them.
The bottom line is you can't fix them. The parents and do-gooders want to fix them but they only make it worse. Eventually everyone figures this out but it is after the crazy person kills them or someone they care about.
You are then left with two choices:
Be proactive and force medication or some form of control of their activities. OR
You do nothing and we continue to suffer ever increasing crime with ineffective policing and justice for the citizens.
The blame goes to the Kennedy Administration for that -- the Community Mental Health Act of 1963 which started the ball rolling on deinstitutionalization. The idea was that thanks to advances in pharmaceuticals for treatment of mental illness, the asylums could be replaced with local community treatment centers where the patients could receive the drugs and still be resident in the community on an outpatient basis. The treatment centers were to be federally built and funded, and then the state would take over their funding and operation, using less funds than the asylums used. However, only a few were built when the budget for the Vietnam War and LBJ's Great Society programs started absorbing the centers' funding and canceled the building program. Sadly, the CLOSING of the federally funded hospitals still proceeded as mandated by the Act. California repeated the mistake with the Lanterman–Petris–Short Act of 1967, signed by Reagan but authored by Democrats, which ended all hospital commitments by the judiciary system. The two acts together resulted in the creation of the large population of street people that persists to this day.
I have no problem whatsoever dealing with crazies on the basis of the law. I place no credence whatsoever in the excuse that a crazy wasn't in a sound mind when he committed his crime.
If there was ANY hope at all for a cure for their condition, then I might be inclined towards leniency for the crazies, but since I have yet to hear of any cures for mental illness, I don't wish a single additional dime of public monies wasted on them.
In my experience, the personality of an individual has more to do with their success in managing their mental illness than anything else. Ultimately, even the most insane are still making personal choices. They are choosing whether to stay on their meds, choosing whether to live a regulated lifestyle, choosing whether to accept direction from a trusted advisor.
Some people are headstrong and make stubborn bad decisions even without mental illness, so they continue their belligerent actions and "you can't make me" choices even if they are treatable. All by a free choice that is outside their diagnosis.
So, I think they should be held responsible for their actions. If they commit actual crimes, they should be sentenced like any other criminal. They may need a special unit to get access to treatment, but otherwise, they are criminals. At some level, they are aware of that, and can benefit from being treated like other adults who must learn to behave in order to live in the outside world.
Hard No for me. "election deniers", vaccine skeptics, gun enthusiasts, etc etc will be in danger of being declared dangerously mentally ill.
Thanks for the plug. I came over to Maggies today after months away. Perhaps not an accident. Your summary of the difficulties is spot on.
I used to be an expert. I have been semi-retired since 2016, fully retired since 2020 and have not kept up with developments. New Hampshire, despite being the "Live Free or Die*" state, actually has the most comprehensive mandated outpatient treatment statute, and has since the late 1970s. The ACLU hates it, as they have too many people who like to conveniently pretend that the evil leviathan SoNH is locking up mere eccentrics and inconvenient people. I have read the old histories, and maybe that was true even up to the 1950s, but not that I have seen.
We use the term "Conditional Discharge." Other states require that someone have committed a crime, or limit treatment to medication, which can be a useless requirement if appts with a prescribing MD are not also required. I understand this is slowly improving nationwide. CD's are not magic, but they help.
* "Death is not the worst of evils" is the seldom-reported second half of Stark's quote.
I will continue in the next comment, replying to myself
The medications generally work to at least improve thinking or mood stability. The structure of the CD can be used with the most severe BPD's to get them past their many emergencies, but only if both the community and the hospital are agreed that this is a quick-in/quick-out-model. Without that, the mandate often makes things worse. The commenters who note that the subjective feelings of the sufferers on medications are unpleasant are quite right. The meds have side effects and patients can feel "like a zombie" or otherwise not fully in contact with the world. It is quite real. It does contribute to going off meds. The complicating factor is that they often do not accurately recall what they felt like when they were ill. They are comparing their feelings in a medicated state to what they felt like before they were ill, or when they were only slightly ill. They do not remember, or misremember their suffering. Also, mania feels rather like being on cocaine, with similar outcome, so it feels desirable even when it is objectively ruining your life. Three weeks ago you felt on top of the world, now you feel like crap. It's hard not to want to go back.
We seldom have to put depressed people on CD's. They want to feel better. Occasionally there are some who become discouraged and inactive so quickly that we have to set up the boundary.
The psychologist Xavier Amador has videos that are marvelous on the subject. He is a research psychologist, his beloved brother had schizophrenia - for which he became guardian - and he is a very good speaker.
You can only get a CD if you have been given an involuntary commitment, for which you have to have been shown to be "dangerous to self or others by reason of mental illness." The state has to prove both ends of that, the dangerousness and the mental illness. It is a complicated process - as it should be, taking away someone's rights like that. NH is a small state, and the judges and attorneys in these hearings know each other and are very clear what is going to fly and what isn't according to the statute. We have a strict State Supreme Court willing to occasionally overturn commitments that fell short of the standard, such as the woman in her 90s who became paranoid and let her heating fuel run out, wrapped herself in blankets in her old home for the winter and only ate what people dropped off for her - but was never in danger of freezing or starvation. We went for the commitment out of pity, but it admittedly did not meet the statute.
It is hard to get a commitment, as many families know to their misery. But all states decide where they want that freedom/safety line to be drawn. People go into mental health to relieve misery and so can slowly become controlling, wanting to make sure patients do "what is good for them" rather than what is necessary for safety. It can get away from even the people with good intentions.
One more reply.
So why don't we do more of it, if it works?
The whole process is expensive. The hospital is always overfull and discharging patients who would at least benefit, if not be "fixed," by a few more days, or even a longer definitive treatment. We are the most expensive item in the state budget. If we replicated the whole system, with another hospital and doubling the number of mental health centers we would do better - but not twice as well. There is a law of low-hanging fruit and diminishing returns. If you wanted to make things really solid for everyone, I figure it would cost about four times what we spend now.
On a related note. Halfway houses are a mixed blessing. It involves putting sick people in with other sick people, who are often street-skill manipulative, dangerous themselves, or even predatory. Families wish we could send their loved ones there because they could relax and not worry about where they were, but they carry their own problems - and the data suggests they do not reduce hospitalisation, even though every thinks they obviously do. "It just stands to reason" is not a good argument for gun control or drug enforcement or a dozen other things, and it doesn't hold up in mental health either.
I have been reflecting recently on the political difficulty of trying to fix things. It is usually liberals who believe that it should just be easy to fix society "We are the richest country in the world..." But on this subject (and education) conservatives are just as bad. We don't like to think about things too hard, I suppose, especially when we can't produce an immediate benefit. But the homelessness/drug/mental illness problem isn't simple, and simple solutions have mostly been tried - over and over again in some cases.
For those who made it this far, thank you for your patience. I just put up a post about The Problem of Good in the middle of the night because I could not sleep after corresponding with an old friend. I have posts on the growth of informal polygamy and the value of marriage coming up. I only say that because it's mostly light stuff on my blogspot page at present, and I wouldn't want you to think I've lost my touch.
Actually, I have lost my touch. I'm going for a long slightly depressed walk now.
Your touch seems fine to me, especially given what a difficult and frustrating career you chose. Did you help anyone? I don't know, probably, but at least you tried.
Enjoy your walk. It is a good time of year for one. Remember to smell the fallen leaves.