Many mentally ill people are still in a position where they can still make decisions for themselves, but their illness means that they choose things that are ostensibly bad for them eg refusing help to get off the streets, help with addiction, stopping them committing suicide, etc. That means society has to decide between forcing people to do things against their will or respecting their decision even though it's what we as a society believe is bad. In order to intervene in someone's life to help them you have to decide how ill someone has to be before you step in.
That is not a straightforward choice, and choosing to let people do things that are bad for them doesn't mean there's anything wrong with the society. It may mean that bad things happen, but the converse, where society steps in when you're deemed 'incapable', might be worse if it's not managed exceptionally well.
As an example, consider whether should someone who is depressed to the point of needing medication be banned from buying alcohol (which is a depressant) because it'll make their situation worse, or should society let depressed people use alcohol as an escape from their illness? Does being ill mean you have to give up your right to decide how to live your life?
In fact, the absolute worst thing you can do with someone whose still "fighting" is to institutionalise them. Once you label and stigmatise them that way, they tend to give up fighting, and whatever benefit they were to society, even in a limited capacity, is then lost.
and choosing to let people do things that are bad for them doesn't mean there's anything wrong with the society.
True, but the discussion doesn't end there. For example: ".. and leaving them to suffer with the consequences of their actions " vs. " ... and supporting them through the negative consequences if it doesn't go well" are very different responses, and certainly do reflect on the society in question.
... and alcohol is a CNS depressant. A common "can't afford to smell of booze right now" substitute (at least in the old days; it's been a very long time between drinks for me) was Seconal. It ain't the same, but it takes the edge off in the right way.
In Oslo, near the university, there used by a "cave dweller". A by all accounts bright student who at 25 decided to stop washing himself. He was soon thrown out of his student accommodation because of the smell. He then decided to take up residence under a tarp in a makeshift "cave" in a hillside next to the university where he stayed for the following two and half decades. In 1987, he was refused the opportunity to take his astrophysics exam because of the smell, and later given a blanket restriction on participating in any exams unless he washed first.
He was repeatedly institutionalised against his will, but in 1988 he won a supreme court decision that made it clear that his unorthodox lifestyle was insufficient grounds for forcing him into mental health institutions. He later sued the University of Oslo over lost income due to the exam ban, but lost.
It may seem obvious that this guy had mental problems. The problem is that in court and during psychological examinations he was fully coherent and defended his choices with references to traditions of asceticism and spiritual beliefs. He understood what he was doing. (EDIT: This does not mean that he necessarily didn't have mental problems, but that he was coherent enough to be able to justify his decisions sufficiently that the court found he was competent to make his own decisions about whether or not he needed treatment)
This poses a challenge, because it can be superficially extremely hard to distinguish actual mental illness from "crazy" lifestyle choices that the person making them are perfectly happy with.
The guy mentioned above was very bright and able to get the resources he needed to protect what he saw as his own best interests in court (all the way to the supreme court 3 times, with one win), but most don't.
Many of these people are mentally ill and need treatment, but we also need to protect those who aren't, and especially those who aren't yet are not resourceful enough to mount vigorous legal campaigns to protect their choices.
At the same time setting the bar high means there are potential high costs and lots of resources involved in helping people that makes it harder to help those who need it out of a concern for e.g. distinguishing resistance and refusals grounded in mental illness from resistance and refusals from people who are mentally competent.
I had to coerce a friend into getting mental help.
He had made some self-destructive statements and a mutual friend reached out to me for help. Several of us scheduled an intervention to try to convince him to go get help and the day before the intervention, he made some more self-destructive statements so that same mutual friend called me and I went to his apartment. He looked like death warmed over. He hadn't been taking care of himself and was extremely thin and pale.
When I asked him to go to a hospital for help, he refused. I told him that I wasn't going to take no for an answer. He had been talking about harming himself and that's all we needed to have him involuntarily committed for 72 hours. He still didn't want to go so I called the police and explained that my friend had been talking about hurting himself and I thought he needed to be committed.
He even threatened that if I followed this course of action, it would mean the end of our friendship. I said that I would prefer to be able to drive past the place where I was no longer welcome than to drive past the place where my friend died because I didn't help him.
The police and paramedics came and the officers explained to me that because of his talk of self-harming, he could be involuntarily committed if he didn't go of his own volition. If he was right and there was "nothing" wrong with him, he could be out of the hospital in the morning.
Their argument persuaded him and he went voluntarily.
He was in the hospital for over a week. Long story short, his problem was caused by the side effect of a medication he was taking for a medical condition. They were able to find a different medicine that helped his condition without producing the side effect of depression. He's doing well today and we're still friends.
Even if the cops had heard him, the doctors who treated him wouldn't know if the cops were lying.
The judge, who had the final say about extending his observation beyond three days couldn't have known if I, the other friend, the cops, the paramedics and the doctors were lying.
There is often more nuance to real-life situations than "I contend that I didn't say that. He can't prove that I did say it."
Namely, my friend needed help. It was obvious to everyone, except him.
It is very hard for a mentally ill person to defend themselves. If they are in a mental institution, they can complain but even legitimate complaints get treated like a mentally ill person being difficult or delusional.
That's sort of understandable - if you are around people all day who hear Satan, or have obsessive compulsions, complaining that you don't have enough bedclothes or the food is bad is just seen as part of your condition. If you get given the wrong medication, it's assumed you are wrong and you'll be ignored. If you get mad about being ignored, you can't just walk out as they wont let you. In all likelihood you'll be tranquillised to keep you quiet.
How do I know this? Everything except the sedation happened to me!
I can't imagine what it must be like to be in that kind of situation. I know how angry I get even when just dealing with customer service people who seems to have a different view of reality than me - being in a situation where people with actual significant power over my life have a different view of reality must be brutal...
It was very, very difficult and I lodged a complaint with the complaints commission over it. The hospital had to apologise to me. I think they realised I wasn't their average patient very quickly, and they had a big problem on their hands!
>(EDIT: This does not mean that he necessarily didn't have mental problems, but that he was coherent enough to be able to justify his decisions sufficiently that the court found he was competent to make his own decisions about whether or not he needed treatment)
Where is the difference between this guy and the one who risks their lives and their childrens' lives by being a missionary in some place where their work can be punished by death? If anything, this man is more sane as he isn't risk his life and the lives of those close to him.
P.S. I'm a religious guy myself, but I am seriously asking this. In many ways religion itself can seem to be a mental illness if it weren't so popular.
> I'm a religious guy myself, but I am seriously asking this. In many ways religion itself can seem to be a mental illness if it weren't so popular.
Look up delusion in the DSM. The definition is more accurate without a special exemption. A close examination of the entire manual will reveal a careful wording to prevent religious people from being diagnosed with any sort of condition.
Simply the fact that this approach is taken says volumes. A rose by any other name...
Mentally ill persons enjoy the same rights that other citizens enjoy and have their own free will.
As long as a person didn't commit any crime and is no risk to society or oneself you cannot institutionalize him or her.
In any case I would refrain from making such broad generalizations about a society. Some societies prefer strong individual rights and others prefer a strong state that tells them what to do.
Some societies prefer strong individual rights and others prefer a strong state that tells them what to do.
That sounds like a false dichotomy. It isn't a choice between institutionalizing people or leaving them to fend for themselves entirely. Whether private or public, the choices made on this spectrum absolutely do reflect on the society making them.
Not to be too rude on the matter, but I'm technically mentally ill by US standards. I have Major Depression, General Anxiety Disorder, and Gender Dysphoria. By your logic, I should be cloistered in some hospital until I "get better" rather than work (which I do in software development for a firm) and participate in society (Mostly online, but it's better than nothing, anxiety sucks).
When does this become a problem such that your naive views makes it impossible for people like me to integrate ourselves into society? Putting up in a soft version of prison isn't going to help us.
I can personally tell you that I have plenty of agency and I understand my situation. Please stop generalizing your naive views, okay?
Even people with fairly severe mental illness can function normally and make rational choices.
A friend of my family studied medicine, and during his studies there was apparently a course where the lecturer used to bring in a mental patient each year.
This specific mental patient suffered from severe delusions. He by all accounts genuinely believed he was the rightful heir of Kaiser Wilhelm II, and had constructed an elaborate fantasy world around his childhood and how he came to grow up in a suburb of Oslo, with a Norwegian family.
But here's the thing: He was in full work (I don't remember as what - a plumber or electrician or something), and lived a seemingly normal, happy life. He functioned fully as a normal member of society in every way.
He had learned and understood that, while he still believed fully in his delusions, people around him thought they were totally crazy. And so he'd accepted he had to live "undercover". He enjoyed showing up in the lecture once a year because it gave him his an opportunity to talk about what he saw as his real self.
He would debate the students at length and expand on details the asked him about with ease.
Did he not have free will?
The point of inviting him was exactly for the lecturer to point out that many forms of mental illness does not remove the patients ability to reason or their ability to function, and that often it can be hard to determine if they are mentally ill at all. What if this man was right? Nobody other than him believed so, but that doesn't prove anything. We assume he was mentally ill, but for many forms of mental illness, the line between ill or not is a fuzzy line that boils down to subjective judgement, and where the more interesting question is whether or not the patient feels there is a problem they want help with.
Of course there are mental illness where the decision is clear-cut too. But mental illness is not a binary. It's not a matter of declaring you "crazy" or "sane".
You can very objectively prove that a person is missing a limb but often you cannot prove that a person is mentally ill.
Often persons will be categorized as mentally ill just because they deviate in their beliefs or lifestyle from the mainstream culture.
And yes, mentally ill persons HAVE a free will, don't tell me they don't as this would be equal to declaring that they are not human beings but just a lump of meat.
They have feelings, desires and goals like anyone else, it's just that these in some cases may be very different from yours or mine.
To add to your answer: mental illness isn't all or nothing, it's not either you're a normal person with free will vs. you're crazy and everything you say is crazy. People with depression, bipolar, many other mental illnesses could be completely normal when you meet them but still classified as having a mental illness. It's possible to keep a normal life, a normal job, yet be aware that you are, in some way, "mentally ill".
This is exactly the problem! The label of "mental illness" is enough for people to throw out the complete capacity of a person merely because they have troubles in a few spots. It's frustrating.
Thank you for the link, I've never heard about Szaz before.
But I must say that I agree with many points he makes although I disagree with some.
In my naive view (this is not my profession) many persons that are just to some degree different are labeled as mentally ill and medicated starting with children that aren't docile enough.
Psychiatry surely has its uses helping people to improve and overcome fears / tragic events or to evaluate if someone can be dangerous but it can't be right to forcefully medicate everyone that doesn't fit our society into submission.
Often persons will be categorized as mentally ill just because they deviate in their beliefs or lifestyle from the mainstream culture.
Reminds me of this quote:
A question that sometimes drives me hazy: am I or are the others crazy?
-- Albert Einstein
Simply being unconventional can be dangerous. Lots of people who were the wrong sexual orientation, skin color, you name it, have been classified in an ugly manner as an excuse to justify mistreatment of them.
In England: People have the capacity to make choices. If you want to take away their rights you need to show they no longer have that capacity.
Capacity is narrowly defined. I might be able to chose where to live, but not chose how to spend my money. I might have capacity for everything apart from what food I eat.
The relevant laws are the Mental Capacity Act (can I chose what I do; what happens if I lose that ability;) and the Mental Health Act (can I be detained against my will; can I be transported to a place of safety for assessment; can I be medicated against my will).
If you live in the UK it's worth having a quick look at the guides for this. You probably won't need it, but it's a good idea to be prepared for the worst. (EG parent gets a dementia illness and starts giving money to telephone "microsoft repair" scammers; your adult child develops a psychosis illness; your co-founder torpedos your business by burying the product on a beach)
In general if you aren't a risk to other people and you're not in danger of killing yourself it's hard for them to hospitalise you against your will. (At least in UK). But it's important that if you have the choice between an informal admission (you go in voluntarily) or section (they detain you against your will) that you go in voluntarily.
I have quite bad depression. That's a mental illness, and I have free will.
My brother-in-law has very bad schizophrenia. I can assure you, he has free will.
You speak about mentally ill people like they are subhuman. They aren't - they are people with the capacity for agency and they have rights. And they should be treated with more respect.
Are disabled people subhuman, because they don't have free mobility? Never said anything like that - only that your illness affects the reasoning, i.e. the will as well. It doesn't have to be all the time as there are different mental conditions affecting people differently at different times.
Many things can affect your reasoning, that is true. But the issue is how do you prove it, and if so, does it even matter what you prove if the person isn't harming anyone?
Coercing someone into psychiatric treatment in some facility until the person "is better" is open ended in nature that it might effectively mean imprisonment for life.
That's why there is (or should be) such a high barrier for this.
Don't get me wrong, I'm really happy for the family in this article and if I knew 100% for sure that (reasonable) action X and Y would have this positive outcome - I would do it.
But the problem is that more often than not you cannot know because we all can't read the minds of others.
There are cases of people living in (for us) unimaginable conditions by their own choice. And some of them are even willing to fight for their right to live in such a way.
On my darker days I sometimes think we live in a hell-on-earth.
In our fiction we describe whole worlds where the Damned are left to shamble around and fend for themselves, cut off from the warmth of humanity. We depict hell as a plane of the existence where the Lost are cut off from all that is right and good in the world, pitched overboard into un-ending darkness and despair.
On my darker days I believe the hell I live in is my own mind. It's not really possible to escape it, though sometimes sleeping helps.
Luckily dark days are few and far between, and I get help. Medication helps, and when it occurs I tell myself it's not reality because, well, it isn't.
You can leave any time you're willing to stop calling us nasty names and accept our help. Or hell, even stop calling each-other nasty names and accept each-other's help. It's not like you're actually damned in any strictly metaphysical sense. It's just that you've got two primary tools, your intellects and your social abilities, your brains and your hearts, and you vilify the fuck out of both of them in favor of fists and fire!
In the USA it's estimated that one third of the homeless people suffer a serious mental illness.
I live in the Netherlands and I think the numbers are the same here. Ofcourse there is help but most homeless people move around a lot so it can be difficult to track them and help them.
Also: having worked with homeless people I know for sure they will get some kind of mental illness sooner or later.
>> I live in the Netherlands and I think the numbers are the same here.
80% of the homeless in the Netherlands suffer from mental illnesses. Source (in Dutch): http://www.ontmoeting.org/dak_thuislozen
I guess the explanation for the difference is that the social security system in the Netherlands is better, so there's less chance for ending up in the street when you lose your job.
I always had the idea that homelessness numbers were way higher in the US than in the Netherlands. This helped keep me firmly on my high horse (I'm Dutch too). Was I wrong?
Apparently there are about 27,000 homeless in the Netherlands[1], out of a population of 15.5 million, so 1,742 homeless per million people.
In the USA there are apparently 633,782 homeless [2] per night out of 319 million people, or 1,987 per million people.
But that's heavily influenced by the way homeless people are counted. The US number is explicitly the number of people homeless on any given night. Estimates of the number of people in the US that will be homeless for some period each year ranges from 2.3 - 3.5 million [3] (7,210 and 10,972 per million resp.) This is estimated from shelter occupancy.
I couldn't figure out if the Dutch statistics agency were counting number of people homeless in a year, or number on any particular night, but [4] hints to me that they're estimating the annual population, so I think the best comparison is:
Netherlands: ~1,700 homeless per million
USA: 9,000 +/- 2000 homeless per million
According to [1], the Netherlands has about 0.16% homeless people per capita, and the USA 0.50-1.10%. (If I'm comparing figures correctly, since that page has "counted on one night" and "total for the year" for different countries.)
It's probably significant that a lot of the US is a lot warmer year-round.
> It's probably significant that a lot of the US is a lot warmer year-round.
Yup, exactly this. It's why there are so many homeless folks in Hawaii: it's easy to live there without shelter. Living in a part of the world where the weather gets cold forces people to make decisions.
I think GP means the percentage of homeless people that have a mental illness is similar to the US, not the percentage homeless compared to the total population.
One third? I think it is much higher, simply for the fact that you almost have to be mentally ill in some form of fashion to continue to live on the street. It's an awful place and I wish it upon no one.
> What kind of society lets a mentally ill man roam the streets, deteriorating, instead of institutionalising him and helping him recover?
What gives you the authority to institutionalize him?
This isn't a snide question. It's a very difficult question that leads to a whole raft of difficult questions.
How do you force a person to take their medication? Why should you do it for this particular person but not that particular person? Who is responsible for the cost of doing so?
> What gives you the authority to institutionalize him?
A government has the duty to provide for the welfare of their people. It's every government's goal to make their people healthier.
> How do you force a person to take their medication?
In a psychiatric institution you could for example inject the medicine into them.
> Why should you do it for this particular person but not that particular person?
If a person's mind is gone so haywire that they're destroying their own body, that they don't have adequate control of their mind (as is the case with schizophrenics), that they don't eat or even respond to human communication, and they have been diagnosed with a mental disorder then you should institutionalize them until their mind regains control.
I once had a very bad episode where I didn't take my medication as I ran out. It's an anti-depressant, not an anti-psychotic or anything like that as I just have depression.
I felt restless that night, and I'd just been made redundant, so I drove my car to an all-night diner. For whatever reason, I somehow managed to go through a red light and a cop pulled me over and issued me with a $500 ticket.
I basically felt destroyed inside. I'd just lost my job, I was hungry, and I felt I'd just let down my family - and I was suffering from withdrawal from the anti-depressants. I freaked out, left my car and wandered the streets. I honestly can't recall much, but I do know it started raining on me and I do know I was thinking about death. The police came and put me in an ambulance. I arrived in the ED, and was placed in a mental health ward.
It was the worst experience of my life. I have never been treated so badly, or had my rights and dignity stripped away so thoroughly and systematically. They didn't chart my medication properly, they put me in a freezing room overnight with not enough bedsheets, the building leaked everywhere (even the light sockets had water going through it), there were people having psychotic episodes or hearing voices, it was terrible food and no staff gave me any counselling or even asked how I was. What's worse was that I recovered very, very quickly so I was fully cognizant of what was happening. When I asked for my correct medication, I was told I was being unreasonable and "You don't get anywhere here by being demanding you know!" was the answer given to me by the nurse on duty (I put in a complaint and then admitted they had made a major mistake in charting my medication).
So THAT'S why we don't institutionalise people. I don't care what facility it is, if the person isn't harming themselves, that's the wrong place for them. I can assure you, if I ever have thoughts of suicide, I will never admit it to the police or any health worker in case they put me back in that place. One night in that place was more than enough. I will either commit the act (God, I hope it never gets that bad!) or I'll suffer in silence.
But people have rights. They have a right to not live in an institution if they don't want to. You want to disregard that right, because you think you know better for them than they do. Many of these people aren't dangerous and don't have infectious diseases, so there's no public health need to lock them up as you're suggesting.
These people don't have control over their mental faculties; they aren't competent enough to make a choice for what is best for them in the same way that minors aren't allowed to go truant or to consent to sex with an adult.
If you are all there in the head, by all means live on the streets, stay filthy, don't eat and ignore people, but this man has a brain disease that makes him lose control of his mind.
If he was forcefully taken to the hospital, forcefully given medication, and recovered he would exclaim "Thank you for saving me! I had a disease in my brain that lead me to believe in crazy things: to be paranoid of police and even medical personnel. I spent 2 years on the streets suffering like this with no place I believed could help me, but you cured me."
If I had a mental disorder that made me go crazy--so crazy that it doesn't even enter my mind that I need help--I would hope that my government would restore my sanity (as I am unable to do so).
How do you decide which ones amongst them are "all there in the head"?
How do you distinguish between someone sane but eccentric that refuses to speak to you, and is filthy and lives rough vs. someone with a mental illness without applying force?
> If he was forcefully taken to the hospital, forcefully given medication, and recovered he would exclaim "Thank you for saving me!
Some would. Others, as I mentioned in an anecdote elsewhere in this thread, would sue you, appeal the case all the way to the supreme court, and win.
> If I had a mental disorder that made me go crazy--so crazy that it doesn't even enter my mind that I need help--I would hope that my government would restore my sanity (as I am unable to do so).
I would too. The problem is that not everyone living like this have mental disorders that make them incompetent to make their own decisions, and separating the ones with real medical needs from the eccentrics is not straightforward.
A large problem is also that often while the official motivation is to help, the impetus for the "help" is that others take offence at their presence or attribute moral failings to them and want them gone, and don't so much care whether or not it helps the person in question.
I think this is the problem left-wing/liberal/socialist thinking. It sounds great - nobody should be on the streets - we have enough resources to house everyone. And then a little while later it's some kind of totalitarian nightmare with people forced to live in institutions as you think you know better for them, and anyone who doesn't agree with your way of life must be insane.
As a left-wing/liberal/socialist, I both believe nobody should need to be on the street, and that it's totally unacceptable for the state to use force to put people in institutions without very strict checks on mental competence.
I find your notion that there's some slippery slope where we'll suddenly want to force people into institutions quite bizarre.
A lot of socialist thinking, on the contrary justifies the need for a welfare system and redistribution with arguments that true liberty is only possible once there are protections in place which ensures that you do not just have the legal opportunity to make your own choices, but also the means to realistically be able to make choices.
On that basis, the argument both for giving people help to get off the street and restricting the states ability to interfere if you chose untraditional lifestyles is the same: Maximizing liberty.
Now, given the old socialist joke that if you put two socialists in a room, you'll get three incompatible definitions of socialism, there may be socialists out there more gung-ho about institutionalizing as many people as possible, but I've not met any.
Conversely I'd hesitate to say it's a right wing issue, despite the fact that historically a lot of right wing governments have been very gung-ho about using draconian measures to force people off the streets and into institutions, including the use of police to remove them coupled with work-houses or even prison next to mental institutions, as many have had a long tradition of seeing homelessness or poverty in general as a sign of moral failings that need to be treated harshly.
But who decides who has control over their mental faculties? Who decides who is competent? The state? The family? The physician?
Can you imagine scenarios where the state, or the family, or the physician are incompetent, selfish, or malicious in determining the competence of a person? I believe there are MANY such scenarios.
This isn't a hypothetical for me... like the author of the article we're discussing, I've had close friends suffer from schizophrenia and depression, and seen one of them involuntarily institutionalized. I wish it was so clear cut SpaghettiCat, but I think the majority of mental health cases are not so black and white as the one in the article.
> But who decides who has control over their mental faculties? Who decides who is competent? The state? The family? The physician?
Who is the most competent to make this decision? The medical professional. Of course government (advised by medical professionals) will set the policy which will constrain the possible decisions.
> Can you imagine scenarios where the state, or the family, or the physician are incompetent, selfish, or malicious in determining the competence of a person? I believe there are MANY such scenarios.
This could apply to absolutely everything: evil police officers taking bribes and releasing criminals, doctors not prescribing expensive medicine to save their hospital money, etc. Does that mean we do away with police protection and hospital services entirely? No, as in this case, we have to accept the risk of the person in authority to make the good decision.
> Who is the most competent to make this decision? The medical professional. Of course government (advised by medical professionals) will set the policy which will constrain the possible decisions.
This has gone poorly quite often throughout history, which is why it's a tough question. Homosexually was officially considered a mental illness in America until 1974.
Note that countries used to do a lot more forced institutionalization than they do now. There were lots of abuses (even in the West, to say nothing of the way it worked in the Soviet Union: https://en.wikipedia.org/wiki/Political_abuse_of_psychiatry_... should be a must-read for anyone arguing for government involvement in institutionalization decisions) and people have backed away from that sort of thing.
It's possible that Europe and the US have swung too much to the other extreme now, of course. But as you say this is very much not black and white.
And there have been at least as many cases of political abuse of the police force, should we also cut down on that just because there is a potential for abuse? Many instutions that are intended to good can be abused or used as political weapons under a totallitarian government, but I think the potential for abuse is much reduced under a more benevolent political system.
Police abuse in a "benevolent political system" generally reads to things like bills of rights and restrictions on when the police can arrest people. Sometimes that means criminals go free.
That's precisely what happened with psychiatric institutionalization: abuses (not just in totalitation regimes) led to restrictions on when it can happen. Sometimes that means that people who maybe should be institutionalized are not.
> These people don't have control over their mental faculties; they aren't competent enough to make a choice for what is best for them in the same way that minors aren't allowed to go truant or to consent to sex with an adult.
Which people? "Mentally ill" people aren't a homogenous group, and the fact that someone is mentally ill and living on the street does not imply that they are incompetent to make personal decisions due to their mental illness. The relation between mental illness, poverty, physical illness, etc. is complex.
There aren't simple answers, and this person isn't these people.
> If he was forcefully taken to the hospital, forcefully given medication, and recovered he would exclaim "Thank you for saving me! I had a disease in my brain that lead me to believe in crazy things: to be paranoid of police and even medical personnel. I spent 2 years on the streets suffering like this with no place I believed could help me, but you cured me."
Would he? He was medicated, functional from the point of view of the broader society, and living in an apartment and stopped taking his medication. Was it because the medication wasn't the best medical science could identify and he was still incompetent though he would be better off with other medication? Did he accidentally stop taking medication and start a downward spiral where he became out of control? Or was he, as he seemed, competent -- but voluntarily decided to discontinue the medication?
> If I had a mental disorder that made me go crazy--so crazy that it doesn't even enter my mind that I need help--I would hope that my government would restore my sanity (as I am unable to do so).
And that's great, but its a mistake to project what you think you would want onto other people as their preferences.
> Which people? "Mentally ill" people aren't a homogenous group, and the fact that someone is mentally ill and living on the street does not imply that they are incompetent to make personal decisions due to their mental illness. The relation between mental illness, poverty, physical illness, etc. is complex.
I was referring to patients who lack control over their mental faculties at least to the degree of the man on which the article was written.
> There aren't simple answers, and this person isn't these people.
Yes, this person belongs to the general collective I described above. Clearly when I said "these people" I meant people like the man in the article I was talking about.
> Or was he, as he seemed, competent -- but voluntarily decided to discontinue the medication?
He may have been in the driving seat when he hypothetically decided to stop taking medication, but ultimately he lost control of the wheel. If a person is not taking care of themself and so out of your wits that you stand for hours at road junctions staring blankly forward, they need to be saved. The authorities must assume that though the decision to stop taking medication was voluntary, because the person lost control of their mind, maybe that person's decision was misinformed (or as you suggest, accidental). By analogy, ust because the driver of a car intentionally didn't buckle themselves in (maybe they wanted to die, or like the risk, or were just eccentric), doesn't mean that when they crash and their body flies out, that we shouldn't hospitalise them.
> And that's great, but its a mistake to project what you think you would want onto other people as their preferences.
Actually there is no mistake here: it's a fact that there are other people like me who want this protection from the state.
Your very insistence that you have the only right point of view on this makes me even more against ever allowing anybody who thinks like you the power to involuntarily commit anybody.
The USA, for all it's flaws, is supposed to be based on the idea that the people are not subservient to the Government's goals, but instead, the Government is subservient to the peoples' rights. That they can only be deprived of their rights through due process of law, as passed by elected legislature. Not a "scientific" book written by people who have no accountability to the population as a whole.
I fear you would not understand how important this is unless you yourself were involuntarily committed. It may well already be true that a malicious individual with enough knowledge could look at your current lifestyle and find a justification for committing you and injecting you with things against your will. I'm sure that such a thing could happen under the rules that you seem to advocate. I hope such a thing never happens to you, but I fear that there are many people who would not see the importance until it does.
It's as much a part of the human condition that power corrupts as it is that we are subject to mental illnesses at times. Many say that it will never happen here. I say that (to quote a line from Battlestar Galactica) all of this has happened before, and all of this will happen again.
> Your very insistence that you have the only right point of view on this makes me even more against ever allowing anybody who thinks like you the power to involuntarily commit anybody.
I don't know what made you think that I have the only right opinion. I'm advocating a view, and actually part of developing a well-rounded view is challenging beliefs you yourself hold--playing devil's advocate.
> That they can only be deprived of their rights through due process of law, as passed by elected legislature. Not a "scientific" book written by people who have no accountability to the population as a whole.
The part of the government that deals with health sets the policy on who should be institutionalised, and they are the ones that give executive power to do so to doctors. Actually, doctors and psychiatrists hold an immense amount of responsibility over the welfare of patients; they may not personally hold accountability, but the hospital or other medical instution does, because of the great potential for lawsuits in the case of mistakes (AFAIK).
> It may well already be true that a malicious individual with enough knowledge could look at your current lifestyle and find a justification for committing you and injecting you with things against your will. I'm sure that such a thing could happen under the rules that you seem to advocate.
This is rather unplausible; there is a mountain of a difference between my behaviour and of an unwashed, malnourished man who fails to communicate even basically with other people, standing for hours at road crossrods like a zombie.
What you're asking for is that people who have the ability to chose (where to live; what medical treatment to have) are denied that choice.
> In a psychiatric institution you could for example inject the medicine into them.
Schizophrenia is a lifelong illness. Do you keep someone imprisoned for the rest of their life so that you can forcibly medicate them against their will?
There are, to change the domain somewhat, other lifelong illnesses, which arent mental disorders. TDR-TB -- totally drug resistant tuberculosis -- is one of these. Worse, unlike schizophrenia, it's contagious.
And the only viable public health responses are either a total quarantine of infected populations, or killing them.
If you reject the latter, and i hope that you do, you're left with a situation not much different from that posed by schizophrenia: the prospect of institutionalisation, but under terms and conditions in which the afflicted will prefer and seek out that option. Or at the very least not resist it.
I'll also note that lifelong imprisonment is not necessarily the only option, you're appealing to the extreme here. Though sometimes, yes, that _is_ what society must do.
> Schizophrenia is a lifelong illness. Do you keep someone imprisoned for the rest of their life so that you can forcibly medicate them against their will?
No, until the mental disorder is controlled. After all avenues of curing are exhausted, and it's still not under control, then they can be released, provided there's no significant risk that they'll harm others or themselves.
So you risk getting into "revolving door" admissions to hospital. A person with a psychosis becomes ill, rejects medication, is detained against their will in hospital and given medication against their will (sometimes by force) until they "become well" enough to be let out of hospital. At which point they're free to decide to stop taking the medication.
I'm not sure that this style of revolving door admission is better for the person than just letting them be homeless. (Although preventing people getting into that situation would be a good idea).
This already happens with homeless people: they become diseased, malnourished, get drunk and hurt themselves. Once the trauma has reached a certain degree that they require hospitalisation, they end up in hospital and released once they've recovered. Are you proposing we not help them at all and just let them fester and die on the streets?
Surely not. The "revolving door" concept, as you call it, is the middle-ground between not helping at all, thus letting a mentally ill person reach trauma more severe, and permanently confining those with incurable mental disorders (but those which can be controlled, and the patient able to live healthily outside the ward), which is both wildly expensive and harder to justify overruling the patient's will and freedom.
No, I'm saying that you can't force people to take medication against their will apart from a few situations.
If you want to provide MH treatment to people it's much better to start with children and young people and better drug and alcohol services, both of which would reduce the amount of homeless people, and also to provide better voluntary MH treatment for homeless people.
People aren't arguing with you because you want to provide MH treatment. People are arguing with you because you want to force that treatment on people against their will.
> If a person's mind is gone so haywire that they're destroying their own body, that they don't have adequate control of their mind (as is the case with schizophrenics), that they don't eat or even respond to human communication, and they have been diagnosed with a mental disorder then you should institutionalize them until their mind regains control.
This is a very fine line. What if someone refuses to eat food, or communicate, as part of a protest or a religious fast or any other personal reason? Who are you do to decide what they're doing is wrong?
If they are not endangering anyone else, it gives you no right to interfere.
Homosexuality was listed as a mental disorder in the DSM until the mid-1970s.
The understanding of relatively highly-occurring afflictions such as PTS and schizophrenia is evolving to this day and it's a near-certainty that the DSM will be a different document 10 years from now.
I don't think we should be so cavalier about taking freedom away from people whose main transgression against the rest of society is making us feel uncomfortable when we look at them.
>Homosexuality was listed as a mental disorder in the DSM until the mid-1970s.
The understanding of relatively highly-occurring afflictions such as PTS and schizophrenia is evolving to this day and it's a near-certainty that the DSM will be a different document 10 years from now.
Just because it had errors before doesn't discredit the document in its current state; it's the product of scientific investigation. By it's very nature it will make mistakes and then update the conclusions as time goes by. Yes, of course it will be different in 10 years, but currently it is our best understanding of mental ailments and the knowledgebase has come a long way.
> main transgression against the rest of society is making us feel uncomfortable when we look at them.
The main transgression is that the victims are trapped in a cycle of suffering because their brains are malfunctioning and are preventing them from recovering or seeking help to recover.
The DSM? Don't make me laugh. The DSM has plenty of things in it that you can't say would require someone to be institutionalised. I'll bet there is something I could find in the DSM that you would fit into. I'm not about to commit you though.
Not every mental disorder warrants institutionalisation; I never said that. My point was to clarify that a medically diagnosed person who does some crazy action should be institutionalised, whereas a person who does the exact same crazy action but has no mental disorders should not be.
Define "crazy action"? And under what mental disorder should someone be institutionalised? All you've referred to is the DSM, so it's very unclear which illnesses and disorders you are referring to.
Incidentally, are you aware that there is a difference between a mental disorder and a mental illness?
By "crazy action" I mean for 2 years wilfully undereating, not washing, living in filth, not responding to basic communication (even to your own daughter) and standing for long stretches of time at road intersections.
>And under what mental disorder should someone be institutionalised?
Under those that are responsible for causing a person to suffer and damage their own health and fail to try to recover, or seek help with recovery, as in the example above.
>All you've referred to is the DSM, so it's very unclear which illnesses and disorders you are referring to.
You've taken this comment thread on a totally different tangent. We're arguing a wholly different point now.
> Incidentally, are you aware that there is a difference between a mental disorder and a mental illness?
I haven't actually taken this on a different tangent. You literally wrote that you would only institutionalize those with a mental illness that is in the DSM, when questioned you said only certain illnesses would apply, so now I'm asking what illnesses and disorders you believe apply.
There are a group of people in Australia called Ferals. They don't eat well, and they never bathe. They do it out of choice. I'm sure some of them are mentally ill. I wouldn't be locking them up in an institution!
> A government has the duty to provide for the welfare of their people.
You state this as if it is an universal principle. It is not. Why don't you and everybody else provide for your own welfare?
> In a psychiatric institution you could for example inject the medicine into them.
Some countries deem persons with certain sexual preferences as mentally ill. (homosexuals)
How would you feel about imprisoning them in a psychiatric ward and injecting some "medicine" against their will to "treat" them.
You may find this example not applicable because it is obviously wrong to do that but I can tell you this much:
No matter how much you feel that you are sitting on the moral high horse and know it all, in a hundred years people will analyze how we acted this very moment and conclude we were a bunch of backward barbarians.
Let's not revert back to the backwards behavior our precursors deemed morally right a hundred years ago.
> If a person's mind is gone so haywire that they're destroying their own body, that they don't have adequate control of their mind (as is the case with schizophrenics), that they don't eat or even respond to human communication, and they have been diagnosed with a mental disorder then you should institutionalize them until their mind regains control.
Which could be translated for many into: Imprisonment for life.
>> Who is responsible for the cost of doing so?
> Taxpayer
And if it's not sufficient we'll just raise taxes and steal even more. Simple solution.
I overreacted here, I don't believe that taxing equals stealing.
It's just how quickly people that have this wish for the nanny state will claim they have a right to your resources for their very well thought out plans.
Plans like imprisoning every mentally ill person and injecting them with some compound against their will.
Usually, mentally ill people are outpatients of medical facilities. However, if they're not a danger to themselves or society, it's difficult to make a case that they should be imprisoned against their will (which is what it would amount to if one institutionalised a person indefinitely).
I'm not saying I know what the answer should be, and this sits on legally and ethically tricky ground all over the world. The mentally ill have been treated pretty badly through history, and I'm not sure that benign neglect is the worst of these options but I do think there should be some formal system of checking on them (informally, there are any number of NGOs and religious groups who tend to keep tabs on the homeless, funding permitting).
"...the deinstitutionalization movement has been widespread, dramatically changing the nature of modern psychiatric care.(7) The closure of state psychiatric hospitals in the United States was codified by the Community Mental Health Centers Act of 1963, and strict standards were passed so that only individuals “who posed an imminent danger to themselves or someone else” could be committed to state psychiatric hospitals."
In broad terms, I agree, and in many cases it is a societal problem. However,
FTA:
>He wasn't a danger to himself or to others, he wasn't threatening anyone, he just didn't look very respectable.
This is the missing condition required to withdraw a patient's liberty in a secure hospital. Even if he presents with severe enough problems to become a voluntary inpatient, he may still wander off and be difficult to find. Due to the nature of this kind of illness, you are likely to cease seeking care when your problems become that severe, and need someone else to push you into it.
Although he had medication that he wasn't taking, it sounds like he was living on his own when his problems became that severe, so he probably had no one to push him to the doctor.
All that said, there should be people looking out for the homeless and making sure they get the medical treatment they need, and maybe the definition of "danger to self" needs looking at, as choosing to sleep rough during a hurricane sounds pretty dangerous to me.
Institutionalisation can be avoided. Properly staffed and trained community mental health services could have intervened while he was still living in his apartment, and probably kept his lease going while getting his treatment back on track.
It's a crying shame to let yet another mentally ill person end up in crisis. He could have easily died or been severely injured.
No, but it's worth considering that when this man ended up in the hospital for a physical ailment they started treating him. That, and his daughter, were enough to bring him back.
If he were to have been hospitalized, not institutionalized, I wonder if the outcome were the same.
Our society assumes mental illness is totally different from physical illness, but in cases like schizophrenia the treatment ends up being very similar. You take your pills and see a doctor. If he had the flu and had suddenly taken a turn for the worse, the discussion wouldn't have been about institutionalization. He would have received treatment in a hospital and then been discharged as soon as possible.
Mental illness isn't always that simple, though. I don't know much about schizophrenia but I know at least some mental issues won't always respond the same way to medication in different people - sometimes different medicines need to be tried, sometimes they need some sort of therapy e.g. CBT either instead of or along side drugs, sometimes they don't get cured at all. I'm not enough of an expert to talk in much more detail, though.
Her dad apparently made a great recovery; the sad thing is that the event that made it possible is a heart attack, i.e. an organic condition. Shows how little society cares about mental illness IMHO (although free will issues have been pointed out)
I read (or skimmed) most of the comments here first, before reading the article. The content of the article was not what I expected after reading the debate here about whether or not to just lock up "crazy"/homeless people.
I am currently homeless. I am not mentally ill. I am medically handicapped. I am very clear what I need. I need an income that does not keep me sick. I find it frustrating to read discussions of this sort.
I think a lot of people on the street would be far better off and face far fewer barriers to getting their life back together if there was dramatically less prejudice. Most homeless people are on the street because they have overwhelming personal problems that society does not have good solutions for, not because these individuals are incompetent. Even if you are extraordinarily competent and know exactly what you need and want in order to get your life functional again, the degree to which you face prejudice and people who are dismissive, disrespectful, and controlling makes it an uphill battle, much more so than I think it really needs to be.
The baseline difficulties are plenty hard on their own if you have certain conditions. But facing so much social stigma and often offered "help" of a sort that makes you want to scream "Please stop helping me!" while denied access to the kinds of help you actually need, that more middle class people can more readily access, sometimes just for asking because they don't face the same stigma and prejudice -- that alone is pretty crazy making. It usually does not go over well to try to comment on such frustrations. People want to see themselves as good and right and do not want to hear that they are making things harder and are behaving in a classist manner. I am often at a loss as to where can you talk about such things and have it be a productive discussion?
I think that really needs to change. If we can change that, then being homeless becomes less of a trap that seems nigh impossible to escape.
There's an idea by the writer, almost lost in the article, that I thought is brilliant:
"When he was in hospital without any documents or ID I came up with the idea of medical bracelets for homeless people. I bought about 100 waterproof USB wristbands which can hold important information and I've given away about 60 so far."
There are any number of people made homeless through mental illness. They are often lost in the system when they become critically ill, and such an identifier would help medical professionals to reunite these people with their families.
Couldn't the same thing be done by a wristband with just a shortened weblink. The advantage is you could update the website and the link could be engraved on the wristband.
I'd have thought a wristband would be too easy to damage/remove - especially if they become indicators of people in that kind of situation. Similarly I think things like tattoos or embedded chips are spectacularly bad ideas - for all manner of reasons.
You could make the wristband hard to accidentally remove, but if it is made out of a decent metal and engraved then it would not be hard to ensure that it survived.
Something like this needs to be voluntary - we really don’t want to be forcing vulnerable people to start wearing something they don’t want to.
I work with homeless people, people in precarious situations, people without ID, immigrants without papers, etc.
I've discussed this very concept multiple times, from multiple angles, with a few organisations.
This issue becomes a real issue of when the person becomes gravely ill, or dies. Most of the time, it's impossible to trace the person's history - contacting next of kin, working out their path until their demise.
This is a real problem to solve.
However, the practical aspects are that this device needs to be non-identifying, and needs also to be non-exploitable by third parties (in particular: police).
Many people without papers are already in a situation that's difficult enough as it is, but this would be made even more difficult by giving police / other authorities a tool to trace, track, and punish.
Likewise, many people in these situations do not WANT to be found, or do not WANT to carry papers.
The conclusion that I had come to would be that these devices are completely encrypted, and provide no form of external data (ID, etc); and a 'read only' industry facing interface would be exposed.
Services, such as hospitals, or indeed police, etc - could lodge requests to a system with this data. The system would register this information, but give nothing back.
The organisation trusted with this information (could be a recognised charity that works with homeless etc) - would be able to, if requested, or required, or at the person's death, be able to access this information.
The end result being, a person holding one of these cards would be able to have a medical history, and be able to build up a map of their lives.
Such things already exist: social security card, etc.
It's a tough problem to crack, once you start to consider the human element.
These are very real and very serious concerns for some homeless individuals. For others, not so much. I think it would be great if the system you describe were available. But I also see nothing wrong with trying to find something simple and easy that works in the here and now for some portion of the homeless population.
I was about to comment about the same thing, it's really brilliant since the medical professionals could also access their medical history in case they land up at a hospital, so that could potentially save lives for a few dollars.
Anxiety and depression are pretty common in the entrepreneur crowd -- these conditions can drive a desire to find independence, some relevance and self-worth.
What makes the entrepreneur different from the homeless person is simply a fighting spirit, but sometimes even those with the spirit give up. I guess the point is, we're all people, and we should all get the same help and respect, whether we're the power-driven entrepreneur or the homeless person who just can't deal with it anymore.
"Beautiful story. Not very relative to HN I think..."
I've been noticing a number of mental health related things on HN. Perhaps it's because these things hit closer to home among this demographic - weather it be personal experience, or that guy we worked with who eventually broke down. For whatever reason these do get voted up here.
Wobbling plates from autism one week, demonstrating the fully armed and operational self-guided self-medicating death-optional star the next. Sure it's not hard dystopian adventure, but if you sit down and write design rules in one mode only, your clone army's going to let you know about the code smell.
Man, so many comments, so many musings about individual freedom and whatnot, and I have yet to see one that mentions the actual, and IMHU perfectly logical, criteria that mental care institutions use to decide whether to intern someone against their will:
"Is this person a serious danger for himself/herself or other people?"
Note that it's not the institution the one to make the decision, but a judge. And, also, taking completely someones freedom away is a very extreme measure that will only be considered for really extreme cases, there are a lot of middle grounds, from compulsory regular visits to the doctor to home visits from the doctor. But all of this, is not usually necessary because most of the people that are mentally ill, know that there is something wrong with them and will voluntarily seek treatment.
It's at least peculiar than when people from the US are asked about mental healthcare, their visceral reaction is "OMG!!! THEY ARE GOING TO TAKE AWAY MY FREEDOM!!!". So much fear, so little idea about how an actual mental care system works.
Source: exGF psychiatrist in a western European country with a strong public healthcare network.
In the US though there is a sad twist to this story. I know a family with a mentally ill adult daughter. They have health insurance, but insurance doesn't want to cover "unnecessary treatments." Sometimes when the daughter has had a psychotic episode or another acute difficulty, insurance has not been willing to cover inpatient treatment/overnight stays. On at least one occasion, the family has waited with fear and danger to figure out how she can get treatment, only to get the blessed call from the police: Your daughter hasn't hurt anyone else (yet), but she totaled her car/got caught stealing/got found by police in the street; since we've arrested her and do believe she's a threat to herself or others we can admit her on a 72 hour hold. And now insurance will cover it.
When compulsory doctor visits are not working, care is not available to those who need it in the US because of cost and insurance. It's not government taking away our freedom here, and it's a pity more Americans don't see this.
Does anyone know why this story is suddenly in the news? I remember reading her original post at least a year ago, which had all of the same photos. Now, I'm seeing it all over Reddit and here. It feels like that Gotye song all over again.
I think it's very unethical that she published the initial pictures without consent (from what I understand, sounds like he didn't know the pictures until she showed him when he was better) even if she is a family member and did it "in good faith" and even when he gave her implicit permission after the fact.
I also can't help but wonder why she didn't bring him to a hospital when she first saw him in the streets. I'm actually shocked that she basically let him wander around knowing his condition.
Thankfully this turned out fine but it leaves me fairly disheartened.
Why wasn't he brought to a hospital by someone, people clearly saw him wandering around. I mean I can understand letting him be and live free if you know nothing about him (other people passing by daily) but she knew his condition and should have intervened herself imo.
US laws about when someone can be detained in hospital against their will vary by state.
You're right that it tends to require immediate risk of harm to other people or to yourself. (And harm to yourself tends to mean risk of death. Self harm, even severe self harm, with no intent to die would usually not be something people are detained for. (Although I don't know much about the US systems.))
Well you can try. From the post it sounds like she "just" (it was obviously not easy) walked away. I don't see that she involved a psychiatrist or tried to get outpatient treatment (whatever that is called in the US) awarded. AFAIK the latter can be gotten if the person is diagnosed and not living safely, I'd say that's certainly possible.
http://www.treatmentadvocacycenter.org/legal-resources/hawai...
I'm probably misunderstanding the post but she had no problem publishing the pictures initially and talks a lot about how hard everything was for her. Apart from the happy end there isn't much about "what did I do to change the situation for him". The time spans are odd, seems like she "just" went on with her life and let him wander about until he finally collapsed.
Once again I'm not trying to say she's heartless or anything but the post is fairly gut wrenching to read. There's too little information on the concrete steps taken to help him.
Nope. For your assisted outpatient treatment, for instance, you must show that the person
"have a history of non-compliance with treatment that has:
been a significant factor in his or her being in a hospital, prison or jail at least twice within the last thirty-six months or [] resulted in one or more acts, attempts or threats of serious violent behavior toward self or others within the last forty-eight months; and
be unlikely to voluntarily participate in treatment; and
be, in view of his or her treatment history and current behavior, in need of assisted outpatient treatment in order to prevent
a relapse or deterioration which would be likely to result in: a substantial risk of physical harm to the patient as manifested by threats of or attempts at suicide or serious bodily harm or conduct demonstrating that the patient is dangerous to himself or herself, or
a substantial risk of physical harm to other persons as manifested by homicidal or other violent behavior by which others are placed in reasonable fear of serious physical harm"
etc. So if he hasn't showed that he's going to harm himself or someone else, there's no help from our health care system, whether the government or insurance. No one will admit him and no one will pay for it. Trying to forcibly or bodily move the guy would be a crime for the daughter.
You can (and people do) argue that by refusing to take prescribed meds the sick person is harming themselves. This only works if you have a diagnosis already, of course.
