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. 


Joel Hassman MD said...

We live in times where there is a growing prevalence in societal mindset that the government, and those who are behind the scenes in what I appraise as an insidious movement, thinks it knows better as the collective than an individual's choice. Very. Slippery. Slope.

For me as a psychiatrist, I have always been very leery and weary to petition people. Sometimes the risk to self and others is fairly flagrant, and to be lucky to have a person involuntarily committed cross my path later and actually thank me for helping him/her be able to regroup and make responsible, well conceived choices not impaired by dysfunctional mood and/or thought is always a wonderful moment.

That said, what about when it isn't so flagrant. I try to remind myself of the scene in M*A*S*H when Hawkeye has the MPs take the Ron Howard character away for being in the war underage, Howard's character saying "I hate you, I will hate you for the rest of my life", with Hawkeye smiling in retort, "well, let's hope it's a long and healthy hate!"

I have had a few of those moments, when patients tell me how vile and terrible I am, and I just try to note they are alive and minimally confined to complain and be angry. Some later get it, it seems often though the comorbid Axis 2 folks just want to cultivate the rage and let it metastasize further. My point here is we aren't here to save the world, no, we are here to help others best help themselves.

Which is what generally frightens me so much of late. We are more and more open to allowing ourselves to agree to weaponize psychiatry. After the Parkland shooting, am I really the only one reading both between and at the lines themselves how psychiatry is going to be dragged into deciding who should be "hospitalized" and have a sizeable spotlight shined on a person deemed a danger to society?! Really, people think Trump's comment about taking weapons and then later letting due process play out will stop with guns? Do people here really remember history and how cultures who "meant well" ended up becoming "mean as hell"?

Sides are not always one or the other. Our politics of late really are just one party, they just fool us to think it is about us or them, but, I think there are a lot of us who are in the middle thinking "um, how are you two really different in the end?"

My hypothesis at least the last two years is we are in a deep Personality Disordered Society, and I ask readers, both providers and patients, to read up on the definition of Personality Disorder, not a specific type, just the general description. Oh, and go by DSM 4 or 4TR, DSM 5 is a lost cause with Axis 2 issues been allowed itself to be manipulated to see personality as an after thought.

So, watch out when you as a provider think you know better who needs to have their autonomy, their freedom, their choice to be over-ruled. Careful, one day you might wind up on the other side of that table in the assessment!

Oh, also from a wise source, Ayn Rand, Atlas Shrugged: beware the clinician who is outraged over the unfair controls over their autonomy to practice, but, beware more the clinician who doesn't care!!!

Luis Alfredo Garcia said...

Your post gets to a point I hoped would be discussed although the NYT article chose not to include it. Nakesha very logically spoke about why the shelter aren't a better option but Breaking Ground is a housing first orgainzation. As has casemanger I had worked with her to get her housing packet completed. Having a completed payciatric evaluation done is part of that packet so that the Human Resources Administration would grant her financial assistance in paying her rent and meeting her other expenses. For reasons that the NYT article does not go into there was pushback against allowing for follow up by any one doctor. She was seen by four doctors all of whom said a follow up would be needed. Why didn't Breaking Ground persue getting her a follow up and diagnosis?

Luis Alfredo Garcia

Dinah said...

I am so sorry, this must have been a tragic loss for you.
May I ask some questions? If Breaking Ground is a Housing First organization, doesn't that mean that they will accept people without sobriety or compliance with mental health treatment being a precondition for housing? Why did she need evaluation by 4 doctors? Was she willing to continue in treatment? What was the pushback? Was she ever treated with medications and did they help?

And I guess I'd like to know if NYC legislation would have allowed for having her brought in for an evaluation and forced care? It seems to me that it may have been possible to at least try bringing this before a judge and that there may have been moments when imminent danger (if that's the NY standard) would have been present: a freezing night, right after she gave birth...

I do believe we should be cautious about forcing psychiatric treatment on those who don't want it, but when someone is tormented, living on the street, this seems beyond my line. And in psychiatry, death is never an acceptable outcome. Thanks for visiting Shrink Rap.

Joel Hassman, MD said...

Just curious Dinah, suppose a patient is forced to be on an antipsychotic, and then has a fatal cardiac reaction to such medication? After all, as rare an event can be with medication, what if a patient develops a fatal arrhythmia and dies before medical interventions could be implemented?

Isn't the physician, or, perhaps the system at large been culpable for this death? Couldn't that be seen by some creative legal interpretation as manslaughter, third degree murder? As I wrote earlier, this is a slippery slope being advocated here, and, when choice is illegitimately ignored, if one's choice is not putting specific people at risk, including the patient who is not actively suicidal or homicidal, isn't that just outright uninvited control?

I offer you and readers with an experience I had in residency over 25 years ago. One night in mid December with the temperature in the low teens in Baltimore, the police brought in a man in his 50s who was just sitting on a bench at the Inner Harbor, who when the police approached him asking him why he was sitting in the cold, he just noted he had no where to go and didn't care about the weather, he was fine. Well, the police took it upon themselves to think the man was suicidal and trying to have the environment kill him. So, at 2AM, they brought him to University ER and had the ER staff wake me up at 3AM to assess him. No spontaneous comments about being a threat to self or others, no psychotic issues, no mood or other thought disruptions, nope, the ER staff took the police opinion the patient was a risk by being outside and not wanting help.

For the sake of space, I came to learn this was a man who was once a professor at a well known Massachusetts college for almost 20 years, who got tired of the rat race, and while had the benefit of not being married nor having children, just quit and decided to live off the fringe of society, migrating south in the Fall and getting to South Carolina or points further south by late December and then coming back in April to the Northeast. Just got a later start that year when I passed his life process that night.

He resented being told what to do, what he was allegedly thinking, and how he should respect others are trying to do for him. He said it with full respect to me, appreciated a warm space, a free meal, and some pleasant company and educational conversation with a resident who listened and respected him. I gave him some contacts to access some transportation at least to D.C. to minimize too much time outside the next day, got him a meal pass for lunch before leaving the hospital that later morning, and wished him well.

Again, the inherent patriarchal attitude among too many physicians, politicians, and elitists in general isn't about doing what is inherently right, but just popular, easy, and convenient for the rule setters, not the public until proven otherwise. Yeah, it sucks to watch people living in squalor, who have little of substance, are at risk for disease and harm from others without basic protections, but, some people make that choice.

When people start making inferences they know what are better choices for others, without considering what others value and want, well, where does that end? Again, history shows not only is "the road to hell paved with good intentions", but the nefarious, antisocial, insensitive bastards almost enjoy seeing the pavement bathed in blood.

Maybe medical schools these days should make graduates have that inscription above their doors for the first year once finished training. Gee, like where the opioid crisis has taken us these last several years?

Just my opinion...

Luis Alfredo Garcia said...

Yes it is a housing first organization meaning they accept tenants who are using substances and also those who refuse treatment. And if you have the money homeless or not you can get a lease from Breaking Ground. To get money from HRA to pay for the apartment a psychological evaluation is required.
I've heard from people who worked there years ago that there were far fewer steps in getting people housing; they were practically just giving out keys.

Dinah said...

So you're saying she was willing to accept housing, spoke with 4 psychiatrists (?psychologists) in accordance with requirements of HRA, and that this wasn't a situation where she was so sick that she preferred to sleep on the street?


harry said...

I think it was and I advocated for what is called a 958 involuntary removal so she could get that evaluation and then housing.We knew enough to say she was mentally ill enough to be a danger to herself.

Joel Hassman MD said...

Yep, there it is, "We knew enough to say she was mentally ill enough to be a danger to herself." Thus my point, the rationalization of weaponizing psychiatry so those who have agendas can hide behind false narratives of "needing to help people" and use hospitalization as a punishment, if not an outright control to disrupt a person in the community.

Hilarious how people forget how psychiatry sometimes operated up to the later 1960s, but, those providers aren't around to remind us now.

Wow, so sad to watch how history repeats itself, but, the need to help at the end of the day has to have limits. I guess it just depends on what group one belongs to define those limits. Yeah, and one better belong to the right group to not be labeled, eh?

Enjoying the travel on that road?...

Dinah said...

Harry, so if an order for an involuntary psychiatric evaluation was filed, what happened? Was it authorized by a judge? Was she evaluated?

In my mind, I feel we should offer people housing and options for voluntary care, before insisting they have involuntary admissions or involuntary treatment. It's one issue if she was so sick she insisted she wanted to live on the street and refused offers for housing. It's another issue if the hoops to housing were so difficult to navigate that she couldn't meet the requirements to get housing she would have gladly accepted. Advocates will jump on this story (as I did for very ill street people) to say We Need Laws to Make These People Get Treatment-- because perhaps even if we forced people to get care, they still wouldn't end up being housed. Maybe we need housing for the ill, addicted, and impoverished.

I do imagine that with all these people so worried about this lady, that if someone had filed to have her involuntarily hospitalized, then perhaps that could have happened with existing laws. In which case, we don't need to change laws, we need to change awareness.

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