Friday, June 10, 2011

Are We Not Thugs?

The voice at the other end of the line was angry and accusatory: "You didn't even talk to me! You never knew my son! You didn't talk to any of us!"

I explained to her that since she had never even met the defendant, there was no way she could have any information that would be relevant to the accused's state of mind at the time of the crime. The victim and the defendant were total strangers and there was no apparent reason for the killing, which made the crime even more tragic. Her son was dead in a random incident, in a crime that was unquestionably motivated only by the defendant's untreated psychiatric symptoms.

The defendant's family was equally shocked and horrified. They were all hardworking solid citizens, with no history of criminal contacts, substance abuse or mental illness. When their daughter started getting sick they knew something was wrong but didn't know what to do. They were all legal immigrants but because they were working at various temporary manual labor jobs they had no benefits and no insurance. They were still working to pay off the hospital bill from their daughter's childbirth, and they were worried about leaving their infant grandchild in her care while they worked. Their culture strongly discouraged discussion of emotional problems, and mental illness was considered a spiritual rather than a medical disorder. When their daughter started talking about spirits talking to her from the TV, they consulted a lay counsellor from their spiritual community rather than a doctor. She got worse, and started staying in her room laughing and talking back to the television. She stopped eating her usual foods, and said that she could only eat fruits because this was how God would turn her into a superhero. She lost thirty pounds and looked horrible. She stopped bathing or taking her antihypertensive medicine. In her eyes, the killing was a test to see if she had the strength to become one of God's warriors in order to save the world. She came across the victim, a ten year old boy, standing at a bus stop. Multiple witnesses were horrified to see the child stabbed to death in front of their eyes. When the police arrived she was still at the scene, holding the knife. At the police station the detective tried to interview her but was stymied by her illogical statements. She repeatedly made the sign of the cross over the detective's head and tried to bless him.

This is a confabulated story, but it's a typical scenario for a classic insanity case. We've talked a lot recently about involuntary treatment, civil rights issues and the anger people feel about being admitted to a hospital or given medications against their will. What we haven't heard about yet is the anger associated with a bad outcome---anger at losing a loved one to murder, anger at not being able to get the treatment you need for someone you love, anger at the unfairness of a society in which treatment can only be afforded to those with the education and financial means to obtain it.

This is where I come in. I have treated people involuntarily and testified at civil commitment hearings and requested emergency evaluations on people who needed care. Am I a thug? What alternatives would the psychiatrist in this scenario have, had the defendant been brought in for care against her will before the crime? If she was too disorganized to clean or feed herself, would she be safe to care for a newborn infant? What about her own medical needs? What would you say to the mother of the murdered child? And would should the psychiatrist in the forensic hospital do, knowing that the patient has just killed someone? Would involuntary medication be appropriate in this case? If not, what would you do?

I'm offering this story for discussion, please keep things civil.

81 comments:

InnocentlyGreen said...

I am not against involuntary treatment if the patient is in undeniable danger of hurting themselves or others.

They may see us as bad people when it happens. But then, in a state of clarity they will be happy knowing we protected them from taking a life. Besides I'm not sure how, as a therapist, one could live with themselves knowing the kill happened because they let the patient walk away not medicated.

Anonymous said...
This comment has been removed by a blog administrator.
Rob Lindeman said...

Thank you for acknowledging that at least one of you DOES practice involuntary psychiatry.

"...unquestionably motivated only by the defendant's untreated psychiatric symptoms."

No, there IS a question as to her motivation. Symptoms don't pull triggers. Diseases don't pull knives. Why is it that when our girl gave money to charity, or volunteered at a food pantry, no one ascribed her motives to forces beyond her control? (hey, you made up a hypothetical, can't I augment it?)

"What alternatives would the psychiatrist in this scenario have, had the defendant been brought in for care against her will before the crime?"

You mean there's no alternative to coercion, force, and fraud?

"What would you say to the mother of the murdered child?"

Your child's murderer will be brought to justice.

"Would involuntary medication be appropriate in this case?"

No.

"If not, what would you do?"

Incarcerate her, as Justice demands. What I would NOT do is excuse her for her crime.

Anonymous said...
This comment has been removed by a blog administrator.
Sarebear said...

Straight out incarceration with no treatment for diagnosed mental illness or no assessment for possible mental illness and subsequent treatment if found to be mentally ill, I believe would fall into the "cruel and unusual punishment" thing that lawyers for civil rights of prison inmates, this argument they use to protect the civil rights of the prisoners (perhaps ironic to some of you since the hypothetical possible forced involuntary treatment would seem to violate their civil rights, in some of your eyes.)

I don't know any of the above for sure but it seems to me that that is the way it is (don't rip me apart for having an opinion that isn't perhaps as knowledgeable as some of you).

If she didn't know right from wrong when she committed the crime, wasn't capable of knowing right from wrong, wasn't capable of knowing that what she did was wrong, I think from what I've read that, simplified, this plays a big part in determining the fate of the defendant and whether or not the insanity defense has a chance, where the prisoner goes whether it be prison or a forensic hospital . . .

There are people who need to be assessed for mental status, possible mental illness, etc. and I suspect there are some people whose mental illness makes them too disoriented, too disorganized mentally, to be able to take medications regularly, and whose mental and/or physical distress (because mental illness frequently has physical symptoms) calls out for medication.

Withholding the needed medication, the needed medical treatment (even though some don't see psychiatry as a valid medical field, it is accepted as such by the majority of society), would be the SAME to judges and much of society as withholding a medication for say rheumatoid arthritis that the prisoner needs.

The controversy here is that unless the arthritis patient is also mentally ill or senile or has other dementia, they are generally capable and quite willing to take the medication for their condition. The patient in Clink's confabulated scenario seems incapable and possibly/probably unwilling to take the medication(s) for their condition.

Sarebear said...

I would rather that some people in prison be forced to take medication when they are incapable of making the decision to themselves, to judge for themselves whether or not to take the meds, when they are incapable of taking it themselves without supervision. I know many of you will not like this opinion, but I see it as, if the patient is NOT treated, it is the same as withholding other kinds of medical treatment from them, which is not how prisoners are allowed to be treated from what I understand, by laws governing their care, that they have access to medical care.

It may not be liked by some, but psychiatrists in prison (er, who work there) are the judges of who needs mental health treatment and who does not; who needs forced medication and/or other treatment (is there other kinds of forced treatment in jail besides medication?) for their mental illnesses if it is so assessed that the patient/prisoner in question HAS a mental illness, and has issues with capability and the other things I've mentioned above. You may not like it, but SOMEONE needs to assess the condition and needs of the prisoners in this area, and that someone is a psychiatrist.

This does not make them thugs, or tools of the state that require access to medical treatment (the withholding of which as I say I don't think would be allowed) and for an incompetent and especially for psychotic patients, the requirement to not withhold treatment would necessitate some situations of forced treatment.

I'm not a lawyer, I'm not a forensic psychiatrist, but as a lay person in society, and regular commenter on this blog, this is my opinion despite my reasonings perhaps being gross simplifications and/or fuzzy guesses about how things MAY work.

If any of my ideas are inaccurate, I suspect the spirit behind them is at least in the ballpark, but that's just my opinion.

No, in my opinion the psychiatrist treating the confabulated patient would not be a thug if they forced medication etc.

I'm sure there are plenty of controversial scenarios where forced treatment would perhaps be even more unclear, and in some cases, used unnecessarily. No system and no one is perfect.

I hope you'll respect that I believe in psychiatry, although not blindly, even if you do not, or if you do not like some of its practices, like forced medication/treatment

Anonymous said...

(AP) NEW YORK - Two men opened fire on a group of young people sitting on a bench on a New York City boardwalk packed with beach-goers seeking relief from the heat, killing a teenage girl and leaving four men wounded. Police said the shooting may be gang-related.

The killers were born to single mothers of low socioeconomic status, and grew up together in the same dilapidated housing project. One of the boy's mother worked two, sometimes three jobs to support her family, the other boy's mother was a drug-addicted prostitute who died of an overdose while the boy was a toddler, leaving him in the care of his elderly, and ailing, grandmother. Because of their circumstances, the boys had little to no adult supervision growing up. They stopped going to their schools and started using street drugs before they turned ten years old. Their role models and heroes were the gang members who ruled their projects, and soon they were "ranked in" to a gang themselves. Because they were juveniles, the adult gang members often used them to run drugs and commit various crimes that would have drawn harsh sentences for the adults. Guns, drugs and violence were common in their world. Conflicts with rival gang members over territory were frequent, and frequently violent. The violence turned deadly one hot day on a crowded boardwalk, in a dispute over an insult, real or imagined, and over a girl.

The incident described at the top is real. It happened today. The background story that follows is confabulated, but realistic. Hypothetically, at what point should we have either involuntarily imprisoned, um, I mean hospitalized, or forcibly medicated the killers, in these confabulated circumstances, given that the possibility they would commit lethal violence was depressingly high?

Rob Lindeman said...

Anon,

I'm confident we could come up with some suitable diagnoses for these young men that would justify their involuntary incarceration and/or medication.

Duane Sherry, M.S. said...

No sooner had I told the Three Shrinks and fellow readers of this blog that I would do my best to tone things down, did you put up a post related to involuntary "treatment" - the post, 'What's Really Insane'...

The passions rose inside. And I spoke my mind, and put up some good links (for anyone interested in reading) to show the unconsitutionality of forced "treatment"... the lack of due process.

I took more than a few deep-breaths today... told myself I wouldn't jump in these types of discussions for a while...

It's hard to not show passion when you put up posts on extreme cases... cases involving forced treatment.

Many of us chimed in on the last one... I gave it my best shot, only to be painted as the "loose-cannon" in the group... Readers going elsewhere... where there isn't such heat...

I'm gonna remain calm on this one, and read what some of the others have to say.

I opt out.

Duane Sherry, M.S.
discoverandrecover.wordpress.com

ClinkShrink said...

Rob: You're right, people don't question motives or mental state for pro-social behavior generally. The general public is often curious about the motives or mental state of criminals, mentally ill or otherwise. The issue of mental state is pretty crucial though in some criminal proceedings because that's how guilt and punishment get decided.

Forensic psychiatrists do not decide guilt or innocence. Guilt is decided by the judge or jury (lay people, not psychiatrists, not clinicians). Lay jurors can and do apply common sense to the facts. They can ignore medical jargon, diagnostic contradictions or inconsistencies and uncredible experts. As SareBear has eloquently (and nicely) described in her two comments, mental state issues and psychiatric symptoms can cause some to not know what they were doing, or to believe they were doing the right thing when they committed a crime.

Rob, you're right that a diagnosis should not be a "get out of jail free" card, and it isn't. In spite of the fact that at least one out of four prisoners has a diagnosable condition, they are prisoners (not hospital patients) because of the fact that they still knew right from wrong. Insanity defenses are successful in fewer than one-half of one percent of all cases in which they are filed.

Of course, all this is moot if someone (including a juror) doesn't believe that mental illnesses exist.

Noni Mausa said...

Many people don't grasp that other people's "free will" is not an absolute, but exists on a sliding scale. Strange, when they generally know that their own will and actions are bent this way and that by a myriad of outside influences.

And that's just the people without serious mental problems -- how much worse for the untreated mentally ill?

Just because you can swim competently in a pool at the Y, doesn't mean you can do just as well in a river, the ocean, or a tsunami.

Of course, we all want to act well. But given the riptides and currents that unsettle us every day, part of the human art of "acting responsibly" lies in knowing how our actions are influenced (chemically, physically, socially and in other ways) and making contingencies so that we reduce bad behaviour and avoid atrocity.

One of those contingencies lies in perceiving and treating severe mental illness.

We're an odd species, hovering as we do "between the stooping angel and the rising ape", and this means we have the thankless task of guarding against our selves, much as we would keep an eye on a puppy or the cattle in the field, to keep them from doing, or suffering, harm. And by that I don't mean some special people controlling others like animals, but all of us keeping a sharp eye on ourselves.

I sure wish we were better at it.

Noni

Anonymous said...

"I'm confident we could come up with some suitable diagnoses for these young men that would justify their involuntary incarceration and/or medication."

Of course, my intent in inventing the scenario was not to suggest that society should come up with a diagnosis that would justify locking them up or drugging them into submission. I'm pointing out the obvious slippery slope we put ourselves on when we start talking about involuntarily incarcerating or drugging people who haven't committed any crime.

I have certain quarrels with psychiatry as a profession, and with a couple of individual psychiatrists, though certainly not with each and every psychiatrist in the world. The three doctors that run this site are obviously thoughtful, and open-minded enough to ask questions and allow open discussion. Several of the psychiatrists that comment on this site are also clearly thoughtful, open to constructive dissent and respectful of divergent opinions. I'm glad these doctors are in the profession.

I also have no quarrel with people who choose to consult psychiatrists and take medications prescribed by them. Many people attest that psychiatrists and their medications have been life-saving. Any life improved or saved is a good thing--something worth celebrating.

But the involuntary incarceration and drugging of an innocent person is something that I will always vehemently oppose, unless a person is demonstrably, specifically dangerous beyond a reasonable doubt. I repeat, beyond a reasonable doubt, which is the standard we use to determine criminal guilt before we incarcerate people.

Here's a story that's not confabulated, though with some details changed. I while back I got a friend request on Facebook from somebody I knew in high school. I hadn't seen him in over 30 years, though I'd been told his story. Diagnosed with mental illness, bitter estrangement from family over refusal to be treated, failed attempts at involuntary treatment. Years of life on the streets. Now off the streets and making his way as a musician. The stuff he's posted on You Tube is good, incredibly inventive. He's had a rough go, clearly, but, aside from the involuntary treatment, he's lived on his own terms, as he chose. Should we, as a society have forced him into a different choice?

What do the psychiatrists who read this blog think should have been done differently for my old friend?

jesse said...

I am re-posting the below that I had posted on What's Really Insane below because it fits Clink's blog better.

Leslie wrote, " I don't agree with that law and would like to see it change to prohibit involuntary hospitalization of people who are oriented and who have committed no crime."

So here was the last situation in which I involuntarily hospitalized someone, over 25 years ago: I was called to an apartment by the building superintendent. My patient had been hearing voices, thought that the devil was sending signals to control him that were coming out of the electric wall sockets, so he pried off the covers with a screwdriver and was trying to stop the devil by pulling out the live electric wires with his bare hands (read this again, it's true that he did this). Apartment a total wreck. He disheveled. Not suicidal. Not threatening anyone. No laws broken. We all (parents, super, and me) were scared to death of what this could lead to.

I went to the police station and signed an emergency petition for him to be brought to a hospital.

What would you have done in my place? And, imagine no psychiatrist had been there. What would the super have done, and what would the police have done if left to draw their own conclusions?

One point I am making is that, even without psychiatrists, people will take action that might be far worse for the patient than what a psychiatrist might do.

You might say, "But he was a danger to others! He was a threat to others!" But does not this conclusion require interpreting what was going on? It requires some judgment. Who should make that judgment? The current laws allow a two physicians to do so, reviewed later by a judge. What would be a better solution?

I hope this is addressing some of AAs questions. They are good questions and should not be ignored.

Rob Lindeman said...

Clink,

Psychiatrists are essential for these proceedings. Without psychiatrists, judges don't render decisions in these proceedings. It sounds like you want to distance yourself from these decisions. I hope not.

As for diagnoses, I'd rather have a jail sentence. At least the latter is finite and defined by law.

jesse said...

Rob wrote: "Incarcerate her, as Justice demands. What I would NOT do is excuse her for her crime."

Fortunately, Justice sees it differently. She does not demand incarceration. This excerpt written at Yale Law School explains it (or, you could just read Shrink Rap, as Clink explains it equally well):

"The McNaughton rule -- not knowing right from wrong:

"The first famous legal test for insanity came in 1843, in the McNaughton case. Englishman Daniel McNaughton shot and killed the secretary of the British Prime Minister, believing that the Prime Minister was conspiring against him. The court acquitted McNaughton "by reason of insanity," and he was placed in a mental institution for the rest of his life. However, the case caused a public uproar, and Queen Victoria ordered the court to develop a stricter test for insanity.

"The "McNaughton rule" was a standard to be applied by the jury, after hearing medical testimony from prosecution and defense experts. The rule created a presumption of sanity, unless the defense proved "at the time of committing the act, the accused was laboring under such a defect of reason, from disease of the mind, as not to know the nature and quality of the act he was doing or, if he did know it, that he did not know what he was doing was wrong."

"The McNaughton rule became the standard for insanity in the United States and the United Kingdom, and is still the standard for insanity in almost half of the states."

jesse said...

The above description of the McNaughten rule was from the Cornell Law School.

We have seen that Rob argues that psychiatrists are distancing themselves from their judgments. Not so. Of course psychiatrists do psychiatric evaluations. Who else should do them? If psychiatrists did not do them the Court would need to have some other profession do them. Which is more qualified, which would you think better able to render a judgment on such an issue?

What is rather curious is that Rob argues repeatedly that there is no insanity defence. Insanity does not exist. Inability to tell right from wrong does not exist.

I cannot tell from what he writes whether he truly believes the positions he holds, or whether he is stating them only to provoke others.

Anonymous said...

To the extent that a person acts involuntarily (as stipulated in Clink's scenario), she cannot be regarded as a human being. Either we regard offenders as sane, and punish them; or we regard them as insane, and, though excusing them of crimes officially, punish them by treating them as beings who are less than human. Let's treat offenders as human beings - it's the only way to offer them a chance to remain human.

Rob

ClinkShrink said...

Rob states: "Psychiatrists are essential for these proceedings. Without psychiatrists, judges don't render decisions in these proceedings."

I'm glad you brought that up; I forgot to mention that in my last comment. Actually, there is no requirement that ANY mental health professional be involved in any legal proceeding (unless expert testimony is required by state statute). Judges decide hundreds of criminal cases every day that involve mental state issues, all without the input of mental health professionals. Judges do their own version of a competency assessment in a standard colloquoy (series of questions and answers) before accepting a guilty plea. In Federal criminal cases experts are barred by law from expressing an opinion on the ultimate issue of insanity. They can testify about a diagnosis, about the symptoms the defendant had at the time of the offense, and whether the symptoms affected the defendant's ability to make moral decisions but they can't actually state an opinion about whether or not the defendant was legally insane. If people wanted to, they could act to change state laws to bar any expert testimony in insanity cases if they wanted to. Some states have even gotten rid of the insanity defense entirely.

And you know what happened?

At least one state found that abolishing the insanity defense was an unconstitional bar to the right to due process:

The Insanity Defense: A Constitutional Right?

Even when an insanity defense is filed, the state still is required to prove that the defendant had the intent to commit the crime and was guilty of the criminal act. After the insanity issue is raised, it then becomes the defendant's job to prove insanity.

Here's a state-by-state breakdown:
State Insanity Defense Laws (I also recommend watching the Frontline videos on that site.)

Jesse: A minor quibble. Forensic psychiatrists don't render judgments---that's for the judge or jury. They offer opinions.

ClinkShrink said...

Rob:

That's exactly the dilemma my forensic patients find themselves in! Society either wants to "lock them up and throw away the key" in a prison, or lock them up in a forensic hospital forever. Neither solution is good, both require humane treatment regardless of the setting.

jesse said...

Thanks, Clink, for clarifying that.

Anonymous said...

I don't know. I guess the best I've got is that people are individuals, and that means that every case for potential violence is just slightly different. God knows mental illness varies. To some degree, there's really no real option pre-violence.

I'm not comfortable with forced treatment on either an individual or a personal level, but I guess I'm less uncomfortable with it then I am with violence resulting from mental illness.

Perhaps the best we can do is acknowledge that it is far, far from ideal or even acceptable. But what other option is there, really? At one point does the freedom of the individual outrank the safety of the collective? And perhaps that's really the core issue. . . .

Anonymous said...

Click, no I don't think you're a thug. I think most people are genuinely trying to help. Jesse, the situation you describe is sad, and it's sad when anyone refuses medical treatment that might help. For example, it's sad that people who don't take their antihypertensive meds despite their physician's warnings end up dying of stroke. I wish they would take their antihypertensive meds and lose weight and control their diabetes, etc. But, unfortunately, many people don't want medical treatment and suffer (and many die) because of it. Hospitals are full of patients who are worse off because they didn't take care of themselves and heed the medical advice given to them. I don't support forcibly treating them, though.

I have a relative who was diagnosed with paranoid schizophrenia about 30 years ago. My family has experienced a lot of grief over what she has gone through and continues to go through. Multiple hospitalizations, my family has paid thousands out of pocket for her treatment over the years. I've seen her on meds, and I've seen her off meds. On meds she doesn't work, doesn't do much of anything, sleeps much of the day, stays isolated, still hears voices, her quality of life sucks. Off meds, the result is also bad, although she doesn't have the comorbidities she had while medicated - like obesity, hypertension, etc., but her quality of life still sucks. On meds or off meds she is permanently damaged with tardive from years of antipsychotic use. Like most people with serious mental illness, she have never harmed anyone. I think this is an important point to keep in mind during these discussions.

I'm not arguing against meds for those who want them, but what about those who don't. What do we do? Do we take everyone who laughs at the t.v. and forcibly treat for life? Where would people like John Nash be if they had not been able to decide to opt out? Is it fair that a psychiatrist gets to decide that my aunt's life with forced treatment and subsequent permanent disfigurement with tardive is a better life, than living off meds and having no disfigurement? I don't think it is, and neither does she. Do we sacrifice the rights of most patients who will never harm anyone to try and save a few who might? I don't think we should.

Leslie

moviedoc said...

Clink may have already covered this, but just in case: A guilty verdict in theory requires mens rea (guilty mind) and actus reas (sp? guilty act). In other words not only must the perp have done the deed, but must have had criminal intent in doing the deed. It seems reasonable to think that someone in the midst of a seizure who unintentionally strikes and kills a victim while unconscious has no guilty intent. That leaves a huge gray area, much of which falls under the psychiatric umbrella. The courts understandably turn to psychiatrists for expert opinions to aid in decisions of fact (fact, not law). Psychiatrists frequently disagree, partly because in most cases some facts support one side, while other facts support the opposing side. The judge decides how the law applies. The jury (occasionally the judge) decides the facts. I was surprised, for example, to hear that prosecution witnesses agreed with defense witnesses in the Loughner case. "Psychiatry" Duane, is not monolithic.

Dinah said...

Clink: Your scenario: Why do we assume that if the woman had been brought for treatment before the horrible incident you described, that she would need involuntary treatment? Maybe she would go and be willing to get care. You have 2 messages here: the indigent who can't access or afford care, and the assumption that if she went, it would be involuntary treatment.
If she came to care as an outpatient--psychotic, unkempt, disorganized, but without an explicit threat or example of dangerous behavior, then she would only be treated if she wanted to be. There are plenty of people like this in the streets of any city.

Anon1 with the scenario of the NY Shooter: Nothing in your confabulated scenario mentions mental illness or psychiatric symptoms on the part of the shooters, but rather tragedies of society. We do think that after someone kills people they should be incarcerated (in prison), yes? At least that is the current sanction/consequence that is in place. Maybe something else would work better, but I don't know what that is.

Jesse: Unless your patient is an electrician or knows about safety and electrical wiring, he is an imminent danger to anyone in the building. A psychiatrist was not needed at this part of the story: a family member could have also gone to the police station to fill out a request for an evaluation, though a judge would then have had to approve it and this can take a couple of hours. Also, police officers called to the scene can fill out these forms and take the patient for an evaluation without a mental health professional if they believe there is imminent danger. People should know that in that setting, the paperwork with the police only gets the patient to the closest ER for an evaluation. About half of people who are brought to the Emergency Room on such emergency petitions are evaluated and released. Many of those who are admitted will come in voluntarily, and those who get admitted usually are in the hospital for only days.

Rob: If I'm reading you right, you don't believe psychiatric disorders exist and you don't believe people should take psychotropic medications. As a pediatrician, what do you do when a parent or child complains of depression/suicidal thoughts or behaviors/ hallucinations/ extreme weight loss due to dieting/ or anxiety that prevents normal functioning? Will you treat distressed children with medicines? Will you refer them to psychiatrists? What about social workers? I don't believe we will convert you to seeing psychiatry as valid, nor do I think you will get us to see that our work is not valid.

Rob Lindeman said...

Dinah,

I'm not sure what you're trying to get me to say. Are you hoping I'll say that I blow off my distressed kids, exposing myself as a heartless jerk? Or that I refer them to specialists or prescribe drugs, exposing myself as a hypocrite? Suffice it to say that I do NOT try to "help" anybody who doesn't want my help, neither do I excuse bad behavior on account of mental illness

Rob Lindeman said...

BTW, why'd you take down those two comments? Too "off-topic" or too "crazy"?

They couldn't have offended you more than any of the "crazy" stuff I've been saying!

Dinah said...

Rob,
I was curious as to how you handle this, and I did mean in situations where people are requesting help. Given the passion of your beliefs, it seems they would present a dilemma in a primary care setting. I wasn't thinking in terms of exposure, hypocrisy, or heartless jerks.

Alison Cummins said...

Rob believes that some human beings are unable to make certain decisions for themselves (the demented) but that since there are no organic brain changes in schizophrenia that schizophrenics are always able to make decisions for themselves.

I have a couple of issues with this. For one thing, it's simply untrue that there are no organic brain changes in schizophrenia. There are. First google hit is here, with references. http://www.schizophrenia.com/disease.htm

For another, it's not an all-or-nothing question.

1) Involuntarily treating someone once does not mean hospitalizing them forever.

2) How is someone whose reasoning capacity is damaged supposed to make an informed decision about meds without trying them? People with schizophrenia very often don't feel "ill." Having an episode feels like the world is changing, it doesn't feel like they are changing. Why should they be the one to take medication when the CIA has implanted radios in their dental fillings? If they are given medication without their consent but their quality of life improves (hateful voices stop screaming insults at them, they stop getting in trouble with the police, they stay in one living situation for an extended period and it's neither the street nor jail, there are no more snakes under the bed, unidentified people stop showing up in the mirror and scaring them) they may decide to stay on the medication even though they don't perceive themselves to be ill. But they can't make that judgement until they actually have the experience of their quality of life improving. In the other case, if their quality of life does not improve or even degrades even after trying different medications, people will stop trying to medicate them (or medicate them as heavily). Both outcomes take time, but life is more than a three-day involuntary admission.

3) It's quite difficult to involuntarily medicate someone for extended periods.

Anonymous said...

Hmm, psychotic, unkempt, but no danger to others would not equal involutary treatment? I'm packing my bags and moving to Maryland.

Duane Sherry, M.S. said...

Earlier in the day, I said I was opting-out of this...

I'm saying it again.
I'm staying out of this brawl.

My God!

'Shrink Rappers' don't put the blame on "passion" on Duane... There's a bunch of it out there!

Quickly, and then I'm outta here.

moviedoc,

You said, ""Psychiatry" Duane, is not monolithic."

I don't think its "monolithic".
I think its "mono-therapeutic."

The vast majority of people (maybe not every single person, but the vast majority) undergo more harm than good (especially in the long-term use, the "maintenance" approach, and especially with the "anti-psychotics").

Also, psychiatry (at-large), not each and every psychiatrist, but a large number (I would say, once again, the "vast majority") walk in lock-step with this "mono-therapeutic" approach).

And, I think we can do better.
Emphasis, on WE.
The medical community has much to learn from the ex-patient (dare, I say, "survivor" community. And conventional psychiatry has much to learn from integrative psychiatry Emphasis on "integrative"... "scientifically-based", non-drug approaches. And there are a BUNCH of them.

Lastly, I am against forced treatment, without due process. Adamantly opposed to forced treatment without due process...

Which brings us back to the brawl.
And I'm steppin' out.

Duane Sherry, M.S.

Duane Sherry, M.S. said...

And in this ring... weighing in at...

My God!

Duane

Sarebear said...

I just want to throw out there that I see an integrative psychiatrist, and she uses medication with me all the time . . . .

I disagree with much that you say, Duane, but I don't believe you'll ever accept my points of view on the matters so that is that.

Anonymous said...

Anon writes, "Hmm, psychotic, unkempt, but no danger to others would not equal involutary treatment? I'm packing my bags and moving to Maryland."

If TAC is correct, apparently there are only 6 states that don't have outpatient commitment (aka "assisted" outpatient treatment): Connecticut, Massachusetts, Maryland, New Mexico, Nevada and Tennessee.

Leslie

Anonymous said...

I think your spam filters have caught my follow up comment on my confabulated gang killing comment. I can't imagine why you would have deleted it.

Thanks for hosting this very important discussion.

Sunny CA said...

As much as I am against forced treatment I can think of scenarios in which I would order it if I were a psychiatrist, though certainly I'd try to handle it without committing the patient first.

What I keep coming back to in my mind, though, is why can't we as a society eliminate the cruelty and abuse present in current in-patient treatment? Why do we have to allow and involuntary electroshock therapy (for which I feel there is a financial motive for the doctors involved)? (allowed in California for anyone involuntarily committed)

I think the involuntary in-patient experience could be more tolerable if patients were treated with respect and kindness and less abuse. Also, wouldn't it be possible to back off chemical strait-jacketing and concentrate on medications that treat the condition? What about hospitals doing anonymous patient surveys on release to find out who the ghouls are among the staff? Everyone in my in-patient experience was in agreement about who was cruel and who was kind. Why are so many cruel workers allowed to keep abusing more patients?

ClinkShrink said...

MovieDoc: Thanks for the additional background.

Dinah: If the woman in my scenario had gone to treatment voluntarily I wouldn't have had an insanity acquittee to write about. And it wouldn't have been accurate. Most of the first-break psychosis insanity acquittees I've seen couldn't be persuaded to see someone.

Anon: I checked the spam filters and there were a couple comments caught there, which are up now. Don't know if yours was one.

Duane: I'm going to do something shocking and agree with you. I think we docs can learn something from former (and current) patients. Thus, the blog. I also am opposed to involuntary treatment without due process. I think checks and balances are important and we need an adversarial system to make sure no single person holds the key to the door. My apologies for responding to your comment since I know you're trying to avoid getting drawn in.

rob lindeman said...

"Without due process" is the key phrase. We protect the rights of accused criminals. What is the due process for the insane person who has committed no crime (unless we stipulate that acting crazy and scaring people is illegal)?
Psychiatrists ought not to be in the business of determining dangerousness. Nobody should. It is an impossible task in theory and in practice can only be applied capriciously (by people who believe they practice scientifically)

Neither psychiatrists nor anybody else should pretend to determine a persons's state of mind in the past (when a crime is committed). It is an impossible task in theory and can only be applied capriciously (be people claiming to practice scientifically)

Zoe Brain said...

How does one draw the line (and I believe there *is* a line) between fanatic religious belief and psychosis?

23. Angels and Demons

We affirm that creatures who have only a spiritual dimension exist, that some serve God faithfully (angels) and others are in active rebellion against God (demons), and that the latter may possess unregenerate persons and oppress or influence regenerate persons. We deny that the Christian counselor may neglect the reality of demons, and that personal problems, organic or non-organic, are never the result of the influence of or possession by demons.
-- The Christian World View of Psychology and Counseling, Mr. George C. Scipione, Th.M., M.A., Chairman • Dr. Lawrence Crabb, Ph.D., Co-Chairman • Dr. Ed Payne, M.D., Co-Chairman • With contributions by members of the Psychology and Counseling Committee of The Coalition on Revival • Dr. Jay Grimstead, D.Min., General Editor • Mr. E. Calvin Beisner, M.A., Assistant to the General Editor

When someone sets their child on fire as part of an Exorcism, "Better that she be in the arms of Jesus than roasting for Eternity in Hell Fire", and can genuinely believe that her actions are not just moral, but heroic - can she be said to have the requisite "mens rea" when a minority of professional psychologists and psychiatrists would agree with her, at least in principle?

You may have seen the UCLA "sissy boy" program recently aired on the ABC. One of the principals was Dr George Rekers, a practicing child psychologist, who co-authored this publication.

Anonymous said...

Dinah, my gang-killing hypothetical was not meant to suggest that we should have locked up anyone preemptively, but to show what that the whole issue of locking people up based on potential dangerousness is, well, dangerous to a free and just society, as well as impossible to implement.

Please see my follow-up comment, which was involuntarily imprisoned in the spam filter, but which has now been freed.

Anon 1

jesse said...

Great question Zoe Brain asked. I can only try to illuminate some of it.

There is a basic differentiation between hardware, software, and programing. Schizophrenia is a brain disease that affects hardware. Major depression also involves hardware: there is a significant drop in neurotransmitters. At times a significant traumatic event will also depress neurotransmitters.

Religious and political convictions are software. The software can be programed, or the ideas created with a particular "key," so that certain convictions are virtually unshakeable, regardless of the evidence presented.

A religious idea such as the existence of spirits can be understood as absolute fact, or they can be understood as metaphors, as descriptions of interior conflicts descibed as external. An example of that is that while some people believe there absolutely are external beings that can come to possess us, others see that in a more metaphorical way.

Psychosis more frequently affects the entire, or at least a large part, of a person's functioning, and can be seen in a person's difficulty carrying out simple instructions, recognizing causality, drawing conclusions, while a religious or political idea can exist along with very high level functioning. It is more likely to be idiosyncratic, as "the devil is talking to me through the electric outlets," as opposed to "we believe there are spirits that can possess the mind." It is solitary, not inclusive.

"When someone sets their child on fire as part of an Exorcism, "Better that she be in the arms of Jesus than roasting for Eternity in Hell Fire", and can genuinely believe that her actions are not just moral, but heroic - can she be said to have the requisite "mens rea" when a minority of professional psychologists and psychiatrists would agree with her, at least in principle?"

There are religious groups that practice self mutilation or even self destruction. The above example needs to be evaluated in terms of a broader examination, not just be isolating the individual beliefs. In our society, religious expression ends when it starts to injure others. While religious leaders or individuals may believe in the absolute reality of demons, none espouse throwing a baby on a fire to rid him of them.

Rob Lindeman said...

Back to brain diseases. You can shout from the rooftops all day long that schizophrenia and depression are brain diseases, but until you produce pathology and pathophysiology you've got only phenomenology.

Schizophrenia and depression are defined by what people do, not by what their bodies show us. With respect for Jesse and Roy (who tossed us a howler about Emil Kraepelin last week), there are brains of textbook schizophrenics that are phenotypically indistinguishable from normals. How do you account for this? If schizophrenia were truly a neurodegenerative disease, like ALS or MS it would be defined by its pathological signs, not symptoms

As for drop in neurotransmitters: giving people a drug that augments their neurotransmitters (assuming this actually happens) wherupon they feel better,proves nothing about pathophysiology.To say so is to commit a logical error

Dinah said...

ARG, Blogger ate my comment!

Rob: you are absolutely right. See
http://www.peteearley.com/2011/03/21/a-chemical-imbalance-real-or-fiction/
for a quote from this book supporting your views. And the authors are...
:~)

Zoe: This is really difficult and I still don't always know. Usually I'm left to do what the patient wants...if you show up in a psychiatrist's office and you are either disturbed by your beliefs or the fallout from them, and you'd like to see if a medication relieves your distress....

Jesse: great answer. How do you explain the Jim Jones Koolaid tragedy?

Coming soon: Horse therapy.

ClinkShrink said...

But seizure disorders often have no identifiable cause or obvious pathology; would you say these are not brain disorders?

Also, the problem with your theory Rob is that gross anatomic (or even histopathologic) changes are often late findings in some disorders. I'm thinking Huntington's disease, where psychiatric (eg. "not real brain disease") symptoms often precede the motor and cognitive changes, with the loss of the caudate nucleaus on brain scan happening last. We also have 20 years worth of PET scans showing changes in dopamine activity and cerebral blood flow in untreated, drug naive people with schizophrenia compared to controls.

jesse said...

The foundation of scientific statements can be religiously based. When that is the case they are maintained regardless of the evidence presented. I know an astrophysicist married to a man who believes the universe was created in six days, from start to man. On the seventh God rested. She simply accepts this and they get along on all other issues. What can be difficult is when the religious position is not acknowledged as such. Debates then can go on for as long as from the big bang to today.

Jonestown: Group suicides (including Massada) may not have been enthusiastically embraced by all. But to the extent they were, group pressure, and the reinforcement of belief, can be a very powerful thing. To learn the extent of the possibilities, read H. C. Anderson's "The Emperor's New Clothes."

Rob Lindeman said...

Seizure disorders prove my point. There is an abnormal EEG.

Similarly, Huntington Disease has a natural history and characteristic pathology.

The most charitable thing that can be said about PET data in schizophrenia is that it is weak.

If this is all you got, you're evidence supports my position.

If mental illnesses were brain diseases, we'd call them brain diseases. Or neurological diseases. The language we use to describe them tells the story

Duane Sherry said...

I've been on tne sidelines for the past couple of days, reading... "listening".

I said that I was not going to jump in, but feel that somebody has to with one point.

It comes from this comment, from ClinkShrink to Jesse -

Jesse: A minor quibble. Forensic psychiatrists don't render judgments---that's for the judge or jury. They offer opinions.

My commment:

Are you kidding me?

The idea that a psychiatrist would think that they were not only able to unilaterally represent the best interests of the state along with the best interest of a patient is hard enough to understand...

The idea that the same psychiatrist would see themselves in a position to be both judge and jury (along with both above-mentioned representative/advocacy roles) is outrageous!

A minor quibble?

Jesse,

The things you learned in medical school about "brain disorders" have never been proven... Your rambling on and on about "sofware" and hardware" is based on nothing scientific.

The idea that you would represent someone in a mental health court, whose very freedom stood on the balance makes my blood run cold.

I tried to stay out.
I couldn't do it.

I close with your words, not mine -

"This speaks to how important it is to doubt our most firmly held assumptions. It is often the ideas we are most certain of that are likely to prove wrong."


Duane Sherry, M.S.
discoverandrecover.wordpress.com

jesse said...

Duane, I agree with most everything you are saying. The word "judgment" can mean simply "opinion," which is how I meant it (like, "in my judgment"), or it can be used as the judgment of a Court. I am not a forensic psychiatrist and so am not so familiar with the proceedings to be able to speak to it with complete accuracy, and so I willingly accept correction.

The fairness of the system is that the psychiatric witness is not even allowed to say "I find this person to have been responsible..." That is the judgment of the Court to make. The psychiatrist can only state his findings, such as "I find this person to be suffering from ...., because of these reasons..."

There may well be a fairer system, but I don't know what it is.

ClinkShrink said...

Jesse has it right. The judge or jury makes the decision, the psychiatrist just offers an opinion.

In a contested insanity case there will be psychiatrists for both the state and the defense, and the lay public gets to decide who to believe.

Duane Sherry, M.S. said...

“… nor shall any State deprive any person of life, liberty, or property, without due process of law; nor deny to any person within its jurisdiction the equal protection of the laws.” – 14th Amendment, U.S. Constitution

Keywords, "ANY PERSON"

For more -

http://archives.gov/exhibits/charters/constitution.html

Duane Sherry

ClinkShrink said...

No Constitutional liberty is boundless and unfettered. Per the U.S. Supreme Court in Addington v Texas:

"Held: A "clear and convincing" standard of proof is required by the Fourteenth Amendment in a civil proceeding brought under state law to commit an individual involuntarily for an indefinite period to a state mental hospital. Pp. 441 U. S. 425-433.

(a) The individual's liberty interest in the outcome of a civil commitment proceeding is of such weight and gravity, compared with the state's interests in providing care to its citizens who are unable, because of emotional disorders, to care for themselves and in protecting the community from the dangerous tendencies of some who are mentally ill, that due process requires the state to justify confinement by proof more substantial than a mere preponderance of the evidence. Pp. 441 U. S. 425-427.

(b) Due process does not require states to use the "beyond a reasonable doubt" standard of proof applicable in criminal prosecutions and delinquency proceedings. In re Winship, 397 U. S. 358, distinguished. The reasonable doubt standard is inappropriate in civil commitment proceedings because, given the uncertainties of psychiatric diagnosis, it may impose a burden the state cannot meet, and thereby erect an unreasonable barrier to needed medical treatment."

Further: "One who is suffering from a debilitating mental illness and in need of treatment is neither wholly at liberty nor free of stigma."

Zoe Brain said...

Jesse wrote:
While religious leaders or individuals may believe in the absolute reality of demons, none espouse throwing a baby on a fire to rid him of them.

Some do. Some teach even more unusual things.

Example :

The pastor, Emanyel Rezireksyon Kris, ordered his followers to fast extensively, to cut contact with their families and told them not to attend school or hold a job, relatives have said.

The fasting rules were so extreme that Rezireksyon Kris told members of his congregation not to swallow their own saliva, referring to it as "poison," said Marie Charles, Janvier’s cousin.

Ovilde told Fields the pastor considered the swallowing of saliva a "sin" in violation of the faith’s fasting rules.

Rezireksyon Kris has not been charged and authorities have not discussed his role, if any, in the criminal investigation.

Anonymous said...

So, let's say the guy in Clink's link is a perfect angel from the moment he is transported to the state institution following his involuntary commitment hearing. From the moment he is there he takes the drugs, he says really I love mom I was delusional and overreacting, he makes his goal for the day during goals group, he colors pictures with great gusto during recreational therapy, he eats the starchy meals without complaint, he grooms himself, and he says thank you to all of the staff for their help - all on day 1 on his stay. How could you say he is a danger to others with such angelic behavior, despite his involuntary commitment? How long are you going to keep him? A week? A month? How do you know if he is a danger or not, maybe he has just learned to keep his mouth shut?

Leslie

jesse said...

Zoe, that's a great point. People in cults are often led to do very extreme and weird things. Mental illness can also occur in religious and lay leaders as much as in anyone else. Some societies hold those who hear voices as having special powers. Some delusions and fixed ideas are isolated from the rest of the personality.

Look at the cultures that are utilizing suicide vests. When children are indoctrinated very young fanatic adherence is more possible.

And Noni, amen three times over. Right on.

Please tell us your ideas!

Lisa said...

Here's another confabulated story: Juan comes from a Mexican-American family. They are poor and have never had health insurance. Juan's father broke his leg many years ago and the family still struggles to pay those bills. Because of this, they fear visiting a hospital or doctor. Recently, Juan has found himself on the floor, not knowing what happened. His brother and mother witnessed him shaking in what appeared to be an epileptic fit. They decided to keep it quiet so as not to worry any one.

Juan drives trucks for his job. One day as he is hauling his delivery, he has another epileptic fit, loses control of his truck, plows into oncoming traffic and kills three children. Juan is found to be free of any wrong-doing. The judge orders that he visit a doctor but ultimately Juan decides that he will not take expensive medication. The family of the three dead children are understandably enraged.

What is done in this scenario? Would Juan be forced to be medicated? Even if he agrees not to drive again, surely his condition could harm someone. Maybe one night he's cutting up a chicken, has a fit and falls with the knife, stabbing his niece in the process. Would doctors suggest that he must be forced to take medication even if he cannot afford it? Even if his religious or personal beliefs dictate a prohibition against medication?

To me, this is nearly the same scenario only with different diagnoses involved. Both have the potential to be a danger to others. I've never heard a person, doctor or lay, suggest that a person with epilepsy should be given involuntary treatment. So why is it different when the diagnosis falls under the 'mental health' label.

jesse said...

In Maryland Juan would need a doctor to certify that it was safe for him to drive a car. There is a medical review board. No, he would not be forced to take anti-epilepsy medication, any more than a schizophrenic is forced to take medication.

An alcoholic who causes an accident can lose his license or go o jail. He can drink all he wants at home.

Lisa said...

Alcoholism is a good comparison to this situation. But alcoholism still falls under the mental illness category as addiction.

From what I got from ClinkShrink's post was that she was arguing a case in support of involuntary treatment. Or at least attempting to prove that involuntary treatment is sometimes necessary to prevent potential violence.

My confabulated story of Juan is meant to ask whether doctors hold the same ethical beliefs that one should be involuntarily treated when their diagnosis does not present a history of potentially violent behavior.

Juan may have his license revoked, but a vehicle isn't the only means of potential danger to himself or others. Should Juan be required to never use a knife or a lighter or swim in a pool? Do doctors feel the same ethical obligation to force Juan to be involuntarily treated? Does the legal system hold an ethical obligation to require involuntary treatment? Let's remember, Juan's diagnosis is not a mental illness but a brain disorder.

ClinkShrink said...

Lisa: There are lawyers reading this blog who could answer this question better than me, but off the top of my head I suspect that Juan would be acquitted of a crime, or more likely not even charged. As MovieDoc said in his comment, in order to be convicted of a crime the state has to prove mens rea (the guilty mind) and actus reus (the guilty act), and both elements must be proven beyond a reasonable doubt. Someone in the midst of a seizure has no mental state whatsoever, and so cannot have a mens rea and is innocent. At most, he might be charged with criminal negligence, if he failed to take his seizure medication and knew that he would likely have a seizure while driving. In that case the judge (not the mental health system) would require him to comply with the state's driving laws, as Jesse said, as a condition of probation. Mental health professionals would have nothing to do with this case at all.

These types of cases are known as "automatism" defenses. Other conditions used in defenses like this are sleeping walking and night terrors. In automatism defenses the defendant claims that he killed or seriously injured somebody during some type of abnormal sleep-related behavior. I've never heard of a defense like this being successful.

Regarding alcoholism, substance intoxication is usually barred as the basis of an insanity defense either by state law or case law. Back in the '60's the U.S. Supreme Court ruled that you couldn't incarcerate someone for being an addict (Robinson v. California). People could be prosecuted for possessing drugs or drug parphernalia, or for selling drugs, but not simply for being prone to using them.

Weirdly enough, Maryland still has an old law on the books from the 1950's allowing for commitment for substance rehabilitation. It allows judges to commit a criminal defendant to a program, but only to a substance abuse program (not mental health facility). The law has never been challenged and no defendant has complained about it because they want to go there. So of course, it's not *really* involuntary treatment. No mental health testimony is required or used for this.

ClinkShrink said...

Lisa: The involuntary patients I see are just the ones who have been found insane of crimes, so they are criminally committed (as opposed to civilly committed) to the hospital. In our state the law allows for a 90 day inpatient evaluation of dangerousness following a finding of insanity. At the end of that time the hospital can make a recommendation for conditional release. The recommendation gets sent back to the judge who ordered the commitment. There is a conditional release hearing, and the judge (not the doctor) decides if the patient--who is no longer a defendant and is not a criminal--is still mentally ill and dangerous. The defendant has defense counsel, and the state's attorney's office and hospital attorney general also are involved in these proceedings. Other states have different procedures (some have no conditional release---they just discharge the patient outright with no mandatory outpatient care).

But getting back to your question (sorry for the rambling lecture, I thought I needed to give some background), all the issues and behaviors you described would be considered by the treatment team when making a conditional release recommendation. The majority of my insanity acquittees look nothing like what you describe though---even when they want medication and take it voluntarily it can take months to years to get better. They just have really bad diseases.

Roy could speak to standards for discharge for civil patients better than I could, but off the top of my head the patient you described would likely be discharged quickly, if a discharge plan could be set up fast (assuming the patient has a home to go to, a doc they can see on the outside, access to meds, etc).

Thank you for your questions and participation; I love talking about this stuff.

Rob Lindeman said...

Thanks for pointing me to the citation of your book at Earley's site. There, you wrote:

"In simpler terms, we presume there is a 'chemical imbalance' [in mental illness], but it remains uncertain as to what that imbalance actually is."

Several of the responses to Earley's post could be summarized by the commonplace "absence of evidence is not evidence of absence".

The problem with this chestnut, and with the excerpt I quoted above, is that they are anti-scientific. An hypothesis, in science, cannot and must not be considered true until proven otherwise. Falsifiability is the linch-pin of science. The equation of mental illness with physical illness cannot be asserted with any degree of scientific rigor. (I have been arguing that as long as you call it "mental illness", you automatically place it in a category outside the physical body, but that is another matter). The chemical imbalance hypothesis, like all the physical explanations for mental illness that preceded it, is regarded by many in the field as religious truth, rather than as scientific hypothesis.

By all means, continue to search for your chemical imbalances, abnormalities in gene expression, and disturbances of glucose uptake on PET. Be sure to get back to us when you find objective, measurable criteria. In the meantime, I'm begging you, please stop asserting you've got what you haven't got.

Anonymous said...

Clink, thanks for the forensic viewpoint, I don't know much about that area. So, when they are found insane of a crime and get 90 days, do they have to stay the entire 90 days if they've made no threats of violence and exhibited no violent behavior by day 10, for example? Wouldn't it be punishment rather than treatment to keep them past day 10 if that's when the violent behavior/threats stopped? What is the rationale behind the 90 day number as the necessary time to see if someone is still violent or not?

Leslie

Duane Sherry, M.S. said...

Locking someone up means locking them up...

It matters not if it's a state prison, a private psychiatric hospital, or the Taj Majal.

And without due process, it's a tryanic act to do so...

And believe it or not, it matters not whether a shrink or social worker sees it as a tyranical act or not.

"Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It would be better to live under robber barons than under omnipotent moral busybodies. The robber baron's cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience." -

C. S. Lewis

Anonymous said...

Duane,

You make some great points. But if you keep lobbing insults like telling Jesse he doesn't have a clue or that he makes you ill, we're going to lose our voice on this blog.

Dinah and Clink have asked for civility and we need to respect that. Actually, we need to practice that without any reminders.

As I previously mentioned, I greatly share alot of your views regarding psychiatry but we have to remain polite. Remember, Mind Freedom, which I know you are a big fan of, constantly stresses that.

David Oaks, the President suffered great abuses when he was wrongly hospitalized. In fact, per your suggestion to Clink to read something different besides psych times, everyone should read this account by him. It would add a whole new perspective to this debate.

http://www.mindfreedom.org/about-us/david-w-oaks/writing/

In spite of what he has gone through, I can't remember a time that he has lost his cool in debating people who vehemently disagreed with him.

We need to follow that example.

AA

Dinah said...

Please note that I will now be deleting comments that contain insults to the bloggers or to our commenters.

Civil disagreement with our view points is fine.

Lisa said...

I fear I am doing a poor job of posing my questions.

First, am I correct in my understanding that psychiatrists and even some of the general public hold a view that involuntary treatment has a place in the medical and legal system? From what I'm understanding, the psychiatrists writing and commenting on this blog see to be in agreement that it's a slippery slope but it has it's merits but is can be a necessary thing if a mentally ill person is an imminent danger to himself or others. Is this understanding correct?

I presented this confabulated story and questions because I find there is a gross flaw in a medical/legal system and a public that finds grounds when involuntary treatment should be used. Why is there a system and a general consensus that involuntary treatment is sometimes necessary to protect the person or the public from the mentally ill but there is no system or general consensus that required treatment be necessary for those with physical ailments?

There was recently a poll on the blog asking whether one would be for or against involuntary treatment (of a mental illness). The majority answered yes. If you changed it to, "If you had epilepsy (or cancer, or diabetes, or a broken toe) would you be for involuntary treatment" I believe the majority would answer no.

I am against involuntary treatment of any kind, no matter the circumstances. I think if there is a case made for involuntary committal for one part of the population -the mentally ill who pose a threat to self or others - then there could be a case for a system of involuntary committal and medication for another part of the population. This is when the belief that involuntary treatment is a vital part of protecting the public welfare becomes dangerous. The question can always be asked, "Why can the woman in your post be involuntarily treated but Juan cannot?" Yes, I understand that some of Juan's activities can be controlled, i.e. driving. But Juan's condition poses a threat to his self and the public just as a mentally ill person could pose a threat.

I'll be clear. I believe mental illness is a very valid medical diagnosis and I believe medications and therapies are proven to treat the symptoms in a way to give the sufferer relief, in the same way that insulin and diet give the sufferer of diabetes relief. But I do not think there should ever be a case where one could be mandated to receive treatment against their will.

Lisa said...

I apologize if my last post may have contained insulting material. It surely was not my intent. I really do want to know why there is a difference in public beliefs on involuntary treatment for the mentally ill vs involuntary treatment for physical ailments.

Dinah said...

Lisa,
Your post was not insulting.
This is not a subtle issue.

Is anyone really having trouble understanding this?

"I believe X and here is why" is fine.

"You are an idiot if you don't believe what I do" is not.

Lisa said...

I do believe my last post was, "I believe X and here is why" and also, "Why is it this way and not that way?" I do not understand why it was deleted.

rob lindeman said...

The two comments you deleted at the beginning of the thread were not insulting, just crazy. Do you have an objective, measurable criterion for deciding what's acceptable and what's not? ;)

Dinah said...

Rob:

Those comments were just too random for me. They show up on many posts with LOL and something that I can't decipher. I decided to delete them this time. Previously we've deleted spam that link to ads. There is no objective criteria.

Lisa:
I didn't delete your post and don't know where it went. It is, however, still in my email trash, so I will repost it for you.

Anonymous said...

Re-posted for Lisa:
I fear I am doing a poor job of posing my questions.

First, am I correct in my understanding that psychiatrists and even some of the general public hold a view that involuntary treatment has a place in the medical and legal system? From what I'm understanding, the psychiatrists writing and commenting on this blog see to be in agreement that it's a slippery slope but it has it's merits but is can be a necessary thing if a mentally ill person is an imminent danger to himself or others. Is this understanding correct?

I presented this confabulated story and questions because I find there is a gross flaw in a medical/legal system and a public that finds grounds when involuntary treatment should be used. Why is there a system and a general consensus that involuntary treatment is sometimes necessary to protect the person or the public from the mentally ill but there is no system or general consensus that required treatment be necessary for those with physical ailments?

There was recently a poll on the blog asking whether one would be for or against involuntary treatment (of a mental illness). The majority answered yes. If you changed it to, "If you had epilepsy (or cancer, or diabetes, or a broken toe) would you be for involuntary treatment" I believe the majority would answer no.

I am against involuntary treatment of any kind, no matter the circumstances. I think if there is a case made for involuntary committal for one part of the population -the mentally ill who pose a threat to self or others - then there could be a case for a system of involuntary committal and medication for another part of the population. This is when the belief that involuntary treatment is a vital part of protecting the public welfare becomes dangerous. The question can always be asked, "Why can the woman in your post be involuntarily treated but Juan cannot?" Yes, I understand that some of Juan's activities can be controlled, i.e. driving. But Juan's condition poses a threat to his self and the public just as a mentally ill person could pose a threat.

I'll be clear. I believe mental illness is a very valid medical diagnosis and I believe medications and therapies are proven to treat the symptoms in a way to give the sufferer relief, in the same way that insulin and diet give the sufferer of diabetes relief. But I do not think there should ever be a case where one could be mandated to receive treatment against their will.

ClinkShrink said...

Lisa: Patients can be released within the 90 days if they are assessed as safe and the court approves the release. More often, they are criminally committed to a secure forensic facility but ultimately can transfer out to a regional non-forensic hospital if things go well. (And if there is a bed available---90% of public psychiatry beds in the country are occupied by forensic patients.)

Involuntary admission does not equate to involuntary treatment. They are separate issues that usually require separate due process hearings.

In the case of medical patients, they can be treated involuntarily if they lack the capacity to give informed consent to treatment. In this case a health care proxy is appointed to make medical decisions for the patient, or a legal guardian is appointed. So yes, it is possible to provide medical treatment against someone's will. Many states also have public health laws that allow for the quarantine of infectious individuals. This is rare, mainly because we have successful treatments for most infectious diseases now and most people willingly accept those treatments. I have heard though of a case in our state in which someone with active infectious drug resistant tuberculosis was taken into custody on a health warrant and placed in isolation. In the 1950's some states had tuberculosis asylums where infectious patients were held until the disease went into remission.

Involuntary treatment is not limited to psychiatry. Civil commitment laws were actually modeled on these medical quarantine laws.

Duane Sherry, M.S. said...

Anonymous,

I think if someone was currently in a psychiatric hospital, forced to take drugs, and/or threatened with ECT, Rob's words would bring them the most comfort... To know that somebody was speaking the truth on this site, however discomforting it might be to the doctors and professionals who post here.

This particular post is not on the subject of medicine, or even law... It is on the subject of freedom.

The post is political.

So it should come as no surprise that the speech (comments) are in-turn political, and heated.

Political speech is not meant to always be polite.

"I would remind you that extremism in the defense of liberty is no vice." - Senator Barry Goldwater

Duane Sherry, M.S. said...

"Whenever violence is used, and injury done, though by hands appointed to administer justice, it is still violence and injury, however coloured with the name, pretences, or forms of law". - John Locke

Anonymous said...

Duane,

The issue is you can speak a very hard hitting truth without insulting people.

Mind Freedom was able to get Ray Sanford and Elizabeth Ellis released from involuntary ECT by practicing this philosophy.

Besides, we're not in Congress as we are guests on a blog owned by 3 psychiatrists. They have asked repeatedly for civility and to keep justifying insults does nothing to advance our cause.

AA

Anonymous said...
This comment has been removed by a blog administrator.
Anonymous said...

"Involuntary admission does not equate to involuntary treatment".

Clink is right; you can spit the pills in the toilet. No one is really looking.

Duane Sherry, M.S. said...

ClinkShrink,

You cite Addington versus Texas:

Due process does not require states to use the "beyond a reasonable doubt" standard of proof applicable in criminal prosecutions and delinquency proceedings. In re Winship, 397 U. S. 358, distinguished. The reasonable doubt standard is inappropriate in civil commitment proceedings because, given the uncertainties of psychiatric diagnosis, it may impose a burden the state cannot meet, and thereby erect an unreasonable barrier to needed medical treatment."

Further: "One who is suffering from a debilitating mental illness and in need of treatment is neither wholly at liberty nor free of stigma."

My comment:

It is said that the U.S. Supreme Court "gets the last guess."

In this case, their "guess" was wrong.

I believe that once the "highest court in the land" is able to clearly see the facts, the next time they're asked to render a verdict, it will be a more humane one... and one that is in keeping with the 14th amendment.

In other words, once they are privy to more of what "treatment" involved, they may begin to understand it for what it is...
"mistreatmnet"...

Timeline for antipsychotics -

http://www.madinamerica.com/madinamerica.com/Timeline.html

Electroconlsive Therapy -

http://breggin.com/index.php?option=com_content&task=view&id=40&Itemid=52

As long as you and your colleagues continue to call this "treatment", nothing will change.

At least until the highest court takes another look.... and I think that day is closer than you and your colleagues are willing to recognize.

Passionately,

Duane Sherry, M.S.
http://discoverandrecover.wordpress.com/warning

ClinkShrink said...

Duane, in the word's of the Supreme Court "I respectfully dissent." With emphasis on the 'respectfully.'

Duane Sherry, M.S. said...

"Freedom is never voluntarily given by the oppressor; it must be demanded by the oppressed." -

Reverand, Martin Luther King, Jr.

Duane Sherry, M.S. said...

Reverend King was peaceful.
His words were inspirational.

But when I read his words, I don't see them as particularly 'respectful'.

In my mind, there was a double-edge sword to what he had to say -

... "I have a dream that one day the state of Alabama, whose governor's lips are presently dripping with the words of interposition and nullification"...

Rather than you and I going back and forth on this subject, maybe we could agree to let Dr. King have the last word.

The 'March on Washington: I Have a Dream' -

http://www.mlkonline.net/dream.html

Duane Sherry, M.S.
discoverandrecover.wordpress.com

Anonymous said...

OMG! Today I had an ER nurse tell me psych patients are demon possessed and that they do not have a medical problem and should not be medicated. Also she used to work in a psych ward. I think she needs to go back - as a patient. I can't figure out why she chose to work in place so diametrically opposed to her viewpoint.

Here's what scares me, and it's not the prospect of being involuntarily committed if I need it. It's lack of access.

I'm scared of needing to be hospitalized and being so sick I can't figure out how to make it happen. That happened to me once a long time ago on a weekend when I couldn't get my therapist or doctor on the phone. It was a waking nightmare. I can't imagine any hospital being worse than the way I felt. By the time Monday came I was well enough to avoid hospitalization - barely, but I don't ever want to feel that way again.

Now I work in a nonclinical position in a small hospital where there are no mental health providers, and from what I've seen the ER staff has an incredibly difficult time finding beds for psych patients. It's not for lack of trying. The nurses spend hours at a time, shift after shift on the phone calling a list of hospitals trying to find one anywhere to take these patients. Psych beds just aren't available. So when psych patients show up, either on their own or with law enforcement, they get evaluated by a psychiatrist over a remote television. After that the ones who are to be committed usually spend days waiting for a bed. Occasionally patients have waited over a week. Few get transferred in less than 24 hours. During this time they receive no mental health treatment whatsoever. Being one of those patients? Needing help? Going days on end without seeing a psychiatrist or therapist? That terrifies me!

Mostly I'd say the ER staff are good people and dedicated professionals, but occasionally their reactions to psych patients can be shockingly ignorant. No matter what the ER staff's qualifications, if I were sick enough to need committing, I wouldn't want to be in an ER guarded by police. I'd want to be in a psych ward or hospital where I could get the treatment I needed.

So no, I don't think you're thugs. I think of you more like guardian angels, and in response to the quiz, "Heck Yeah! I'd want to be committed if I were dangerous or suicidal or otherwise so sick I couldn't take of myself." I just hope if it ever comes to that I don't spend a week stuck in an ER being babysat by the police, although I guess, that's still preferable to being alone and suicidal.