Sunday, March 04, 2018

On Forcing Street People to Get Psychiatric Treatment

In the New York Times, Benjamin Weiser has a beautiful and moving story about Nakesha Williams, a lovely and vibrant woman who graduated from Williams College and then became ill with a psychotic disorder. She lived for years on the street in New York City.  Please do surf over to Mr. Weiser's story, "A 'Bright Light' Dimmed in the Shadows of Homelessness." 

The story is a tragic one about a promising woman whose future, and ultimately her life, are lost to mental illness.  Despite so many people who loved and cared about her, and so many who tried to get her help, Ms. Williams dies alone on the street. She is young, and she dies of a treatable disease, a pulmonary embolism.  Mr. Weiser does a commendable job of re-creating her story and tracking down the people who knew her in the years before and during her psychiatric decline.  To his credit, he just tells the story;  he doesn't turn it into a plea for laws that make it easier to involuntarily treat people, and he doesn't go on about how this was a life that could have been so much different if only she had been forced to have psychiatric care.  I found the story to be a richer one told simply as it was without the moralizing.

So having said that, I am now going to invoke my role as an expert on involuntary treatment to talk about the plight of the "homeless mentally ill."  Why the quotation marks?  Well, first I'd like to differentiate those who are homeless from those I prefer to call 'street people.'  You are homeless if you are an adult without a stable residence, and most people who are homeless are not sleeping on the streets.  They may be in shelters, in motels or the single room occupancies, or staying in the guestroom or on the couch of a friend or relative.  Those who are actually sleeping on the streets are our society's sickest and most disenfranchised members.  The quotations also serve to remind me that "the mentally ill" is not a term I like to use: these are people with psychiatric disorders, not to be defined by those disorders.  While many like to talk about the plight of the homeless mentally ill, I'd like to suggest that as a society, we should invest our resources in helping all of our countrymen who sleep on the streets, whether they are mentally ill, addicted, or simply indigent.  

In a wealthy country such as we are, the fact that there are people who spend their nights on the street should be a source of shame to all of us.  Logically, this can't be about money: there is nothing cheap about leaving people on the street-- to start with, they have high medical expenses, and high incarceration rates.  One way or another, they cost us all money.  Personally, I don't believe it should be legal to sleep in public places, and as a society, we should feel obligated to provide sick and destitute people with  more than a nighttime cot in a room with other people where they may not be safe.  

If you've followed my Shrink Rap posts, or read our book, Committed: The Battle Over Involuntary Psychiatric Care, then you know that the issues of involuntary treatment are nuanced and complex, and that I think it should be avoided when possible as there is the risk that involuntary care leaves some people feeling  traumatized and angry, and because we all cherish the right to make our own medical decisions.  You also may know that I'm not much for invoking "anosognosia" as a reason to force people to have treatment, and do see my post on this over on Psychology Today.  But you may also know that I believe there are times when there really seems to be no choice but to force treatment, and when it is simply the right thing to do to keep everyone safe.  A traumatized patient is better than a dead patient.  

So what about Nakesha Williams, and others like her who are "dying with their rights on."  I messaged Mr. Weiser, the NY Times journalist, and asked him if she had ever been treated.  In the article he talks with friends who have tried to get her help, and with case workers from a mental health agency who tried to engage her, all of which she refused.  Mr. Weiser thought Nakesha had been in treatment briefly when she was younger--he didn't know for sure if she had ever taken medications-- but it does not appear that she had any treatment in the years she lived on the streets of New York City.  Her family had long before lost contact with her.

So Mr. Weiser didn't say it, but I will: if people suffering from psychosis are living on the streets, unprotected from the elements, at risk of illness or of being prey to criminals, and they are so ill that they are refusing offers of housing, healthcare, and help getting financial entitlements, then they should be hospitalized and treated against their will.  As traumatic as forced care can be, I believe it is preferable to the obvious risks people on living on the streets face each and every day, and would offer them a chance at a safer and more productive, less tormented existence.  Ms. Williams was certainly a risk to herself, and her story is one of society's shame. 

So do we need new laws to get Ms. Williams and those in her situation care?  I don't believe we do: she was a risk, as can be seen by her untimely death, and as I've said above, I don't think it is a person's right (or it shouldn't be) to live in public places.   Would treatment -- and in this case, I specifically mean antipsychotic medications-- have changed her life?  I don't know, but I would hope so.  

There, I said it.  Now please let me add a plug for Housing First options that place people in housing without first requiring them to be free from drugs or alcohol, or to accept psychiatric care, as a condition of housing. 

Thursday, March 01, 2018

What's Caught My Attention Lately....

It's been just about a month since I last posted here, and what a month it's been.  I was away for a couple of weeks on a wonderful family vacation to Vietnam and Cambodia.  While it was a mostly psychiatry-free trip, the sign above did grab my attention.  It was a sign at the ecolodge where we were staying in Mai Chau, a rural area of Vietnam where water buffalo are still used as work animals in the rice paddies.  Why are persons with mental illness not permitted in the pool?  I have no idea, but it seems that stigma is rampant everywhere.  

So do let me give links to the things I've been writing and thinking about.  

~When I last posted on Shrink Rap, it was in response to Pete Earley's mention of 'the worried well.'  Pete also ran my response   and John Snook of the  Treatment Advocacy Center wrote Pete a separate letter which he put up as it's own post.  By all means, do join in the fuss over on Pete's Facebook page where he entertains comments. 

~I moved venues and put up a somewhat related post on PsychologyToday called The Perplexing Semantics of Anosognosia: Why An Obvious Phenomena Has Sparked Controvery.   See what you think, and I look forward to your comments.
~Over on Clinical Psychiatry News, I've written two articles on everyone's favorite topic: Medication Prices.  In the first article, I did some comparison shopping for Abilify (aripiprazole) and Provigil (modafanil) and found that the prices varied by HUNDREDS of DOLLARS (and yes, I did mean to yell) per month, depending on the drug store.   In the Second article, I interviewed co-founder Doug Hirsch and learned about how drug prices are set and why GoodRx is able to offer deep discounts.  

Finally, I'd like to send you over to today's New England Journal of Medicine to read a powerful article about a surgeon who was involuntarily treated for a suicidal major depression.