Quantcast

«

»

Jul 01 2014

So that’s mental illness

Read this account of a man slipping away into madness. It’s not about melodrama or violence, but about an ordinary person drifting towards paranoia, cutting off all contact with his family, and acquiring strange obsessions in place of normal human relationships. It’s harrowing and tragic.

The story also points out the social and legal difficulties in handling these cases. The man is clean and presentable, he can engage coherently for periods of time, and he will tell you that he is not sick — which means everyone is helpless to deal with his problems, and for good reason.

Once, the man’s family might have handled the situation by having him involuntarily committed to a psychiatric institution. For decades, it was a routine and simple procedure: If a doctor agreed that the patient had a mental illness, he could be institutionalized even against his will.

The problem was that it was a process with few safeguards, and during much of the 20th century, all kinds of people who didn’t belong — from free-thinking women to gay people, minorities and rebellious children — wound up locked in hospitals where abuse was common and conditions were often bleak.

So the system changed, with one catalyst being a 1975 Supreme Court ruling that effectively restricted involuntary commitment to instances when a person becomes a “danger to self or others,” a phrase that now appears in one form or another in state laws across the country.

Keep that in mind next time someone declares that labeling someone “mentally ill” is a good response to a problem.

77 comments

Skip to comment form

  1. 1
    Erlend Meyer

    Point well taken. Personally I try to avoid diagnosing people, but at the same time there are people that are obviously “crazy” due to either mental illness or an irrational belief system. For instance most conspiracy fanatics presumably aren’t suffering from any mental disorders, but they’re still “nuts”. Question is, how and to what extent can one differentiate between these?

  2. 2
    playonwords

    Thank you.

    There was a time when my depressive illness came close to psychosis but thanks to an understanding family, employers with a good social care scheme and the National Health Service I pulled though it eventually. I too had isolated myself, stopped communicating, and begun various compulsive and self destructive behaviours. Becoming functional again required 5 years. Then a few years later a bad choice drove me down again for another few years of compulsion and recovery.

    Coming up on 20 years without relapse.

  3. 3
    busterggi

    I see too many situations similar to this, mostly via work, they rarely end well.

  4. 4
    Gorogh, Lounging Peacromancer

    Unfortunately, I don’t have the time to read everything right now, but from what I’ve seen, “harrowing and tragic” are perfect descriptors. Actually having worked at a psychiatric hospital for a year (closed ward for patients with chronic psychosis), I have had some first hand experience. Schizophrenia (or similar illnesses such as this) can be extremely disturbing.

    Still I feel compelled to add this comment. This is a mental illness alright, but even less colorful symptoms qualify. I assume that the headline was intended as a contrast to the mental illness-hypothesis thoroughly discussed in the Elliot Rodger-case. That hypothesis is neither necessary nor sufficient to explain his behavior, and it is therefore beside the point to put it in the focus of attention. If we are actually talking about mental illness however, let us not make the mistake of somehow stratifying it into more or less legitimate (no Akin-allusion intended), but keep the nuances in mind.

    Again, I am sure that was not PZ’s intention. I certainly mean no offence.

  5. 5
    Fukuda

    Point well taken. Personally I try to avoid diagnosing people, but at the same time there are people that are obviously “crazy” due to either mental illness or an irrational belief system. For instance most conspiracy fanatics presumably aren’t suffering from any mental disorders, but they’re still “nuts”. Question is, how and to what extent can one differentiate between these?

    Years of training are required to accurately diagnose people, unlike internet diagnosers who think the DSM is some kind of magic list. Actually, there’s no evident overlap between holding weird or irrational beliefs and mental illness. That’s an unlucky but popular belief based on general ignorance of mental illness.

    Mental illness contains a relatively small and cicumscribed number of disorders among the enormous group of neurologic disorders. It is not a blanket name to assign on people with either neurodevelopmental disorders (no, autism isn’t a mental illness), personality disorders or “weird”/difficult to understand people.

    It (usually) implies a combination of some but not all of the following: changes in conscious evaluation of oneself, reasoning abilities, planning and attention, mood states and/or other higher mental abilities, not just “weirdness” or inadequacy.

    You can have MDD, OCD or even (yes) schizophrenia without holding more irrational beliefs than your average joe. And you can be perfectly aware of your disorder, which is another quite big difference between them and your irrational average joe.

  6. 6
    Great American Satan

    The article is concerned that protections meant to keep healthy people from being locked away against their will have gone too far, that they are keeping people who need to be committed away from help. The article is too long for me to read in its entirety right now, but I didn’t see anything proposed to take the place of those protections. They are needed. Of course, sometimes an article has to raise a question for which the author has no answer.

    A much larger problem for commitment – involuntary or otherwise – is the horribly inadequate funding for mental health services. There is precisely one mental health asylum in my state, and this isn’t the upper midwest. People are put back on the street all the time, including a few high profile cases that ended in murder over the last several years. I wonder sometimes when I see a red faced homeless person screaming about the jews at three AM, is he trying to get put in jail just to get out of the cold? The resources need to be there and they sure as hell aren’t.

  7. 7
    skeptifem

    I know that Florida lets families force treatment for substance abuse. You need 3 family members willing to testify that the person needs help & petition the court for an order. I don’t know if it works the same for other conditions. I don’t know the outcome of their system either, but it seems like a good idea and prevents a single person from being responsible for the decision making about treatment.

  8. 8
    A Masked Avenger

    I’m not a mental health professional, so my opinion is worth slightly less than you paid for it.

    I have been in therapy for many years, though, and from where I sit it does feel like there’s a bit of a continuum. I don’t have any identifiable organic problems, but experienced depression (successfully managed both with and without SSRIs) and an anxiety disorder. The anxiety disorder boils down to a cognitive distortion around some genuinely harrowing experiences. It rose to the level of a “disorder” because it was crippling: anxiety about re-experiencing these problems, and extreme measures to prevent and control things I feared could lead to them, significantly interfered with living a normal life.

    Although drugs were prescribed to take the edge off the worst problems, it didn’t take too long for CBT to get the problem under relative control without the drugs. CBT also helped greatly with depression, along with stress management methods like meditation (hat tip to Greta Christina).

    Based on my lay knowledge, I’m sure that some psychological disorders are purely organic conditions affecting the brain. I’m sure that some are a combination of organic and cognitive. But I very strongly suspect that some disorders are purely cognitive in nature: some cognitive distortion(s) that causes significant impairment or suffering. The DSM-IV seems agnostic on the need for an organic basis:

    …[A] mental disorder[s] is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one. Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as described above.

    They admit that the definition is extremely fuzzy. A random paraphilia wouldn’t be considered a disorder just because it’s unusual, or just because everyone else is disgusted by it, but it would be considered a disorder as soon as the person came to regard it as a cause of suffering, or if the person was unable to avoid engaging in it in inappropriate ways that, for example, kept getting them arrested or fired, or that kept leading to failed relationships.

    My own disorder wouldn’t have been diagnosed if I’d found a like-minded community, or adopted a coping strategy (even one as extreme as joining a monastery or the military, say), or if I considered myself satisfied with my life. I’d have merely been an odd duck who was unusually scrupulous about my handling of money and relationships with strangers and employers.

    I don’t see much point in pathologizing racism as a mental illness, but I also don’t see any fundamental difference between racist ideation and my own cognitive distortions. A racist who dislikes minorities the way I dislike Pepsi products clearly doesn’t have a “disorder.” Even virulent racists often suffer no impairment, because their lives are structured to accommodate it–by living among and associating with other virulent racists, for example. If a virulent racist moved to a liberal enclave, where everyone held him in contempt, wouldn’t magically change his racism into a disorder. But if he was unable to hold down a job, because he mistreated black subordinates, fought with black coworkers, and was insubordinate to black supervisors, we’d be edging into “disorder” territory. If the racist recognized his inability to hold down a job or a relationship were recognized as a source of suffering and distress, then he’d almost certainly be diagnosed with a disorder. I’m not a clinical professional, but I suspect the diagnoses wouldn’t be “racism,” but rather some other disorder that describes his antisocial behavior in more generic terms.

    I guess the upshot is that I (as a non-expert) don’t see mental illness as a binary condition. That doesn’t mean it’s helpful to classify every cognitive distortion as a mental illness, because then everyone is mentally ill. But it feels more correct to regard it as a continuum, and to regard other things (like racism) as also occupying continua, and to recognize that those continua can overlap.

  9. 9
    Pyra

    I’m not convinced by this article to allow the protections fought to be put in place should be modified. Enough people from my life suffered at the hands of those in authority, because here, it is still easy enough to get involuntary commitment. This article scares the shit out of me. I have a long story that I won’t go into, here, from just a couple years ago that makes it more chilling to me. No… those protections are there for a very good reason. The abuses are very real. Until a person actually does something, that person should be considered innocent. Including the mentally ill, thank you…

  10. 10
    raven

    Schizophrenia – Wikipedia, the free encyclopedia
    en. wikipedia. org/wiki/Schizophrenia

    The average life expectancy of people with the disorder is 12 to 15 years less ….

    Factoid.

    Schizophrenics don’t live all that long. Average life expectancy is 12 to 15 years less than US average. This number varies a lot by state. Sometimes it is up to 25 – 30 years less.

    I’m sure most of us have seen this at one time or another. One young woman died of anorexia, one middle aged guy died of hypothermia…in his front yard in a residential neighborhood, and so on.

  11. 11
    magistramarla

    I dealt with this with my mother. She could appear to everyone to be the perfectly calm, sweet widow with a teen to raise. When we were alone, she was abusive, mean, vindictive and often out of control.
    No one would listen to a teen-aged girl, so I left, went to college, got married and started a family.
    Years later, when I was called to the hospital because she had to be hospitalized for a physical illness, it became clear to her doctors that she was psychotic when she attacked a nurse.
    I was asked how long she had been like this and told them that it was since I could remember during my childhood. I signed off on having her involuntarily placed on a psychiatric ward and then later moved to a nursing home equipped to dealing with her mental and physical problems.
    I’ve often wondered if someone had paid attention to a frightened and abused little girl, if she could have gotten help much earlier in her life and avoided much pain for herself and me too.

  12. 12
    twas brillig (stevem)

    to instances when a person becomes a “danger to self or others,”

    [smartass warning] So that’s why EVERYone was so quick to label Elliot “Insane”, cuz he WAS a danger to self AND OTHERS.
    [/smartass]
    Mental health is a *difficult* subject. It is so subjective, to define “health” of the brain’s functions. And most words used for different states of the brain have become immersed in colloquial misinformation that it is sometimes frustrating, when using the words absolutely correctly. Such as dementia, most think it is just a euphemism for “crazy”, but anyone who has cared for their elder loved ones suffer through dementia know that it means a loss of one’s previous abilities with their brain. And depression is more than just perpetual sadness, it applies to much more of the “normal” functioning of the psyche being different than “normal”.
    apologies, my own struggles with brain injury leads me to write things like this that I previously would have. It is known as disinhibition that is often a result of TBI. One effect I see, is that I watch myself thinking that I know better than everyone else and must tell everyone the correct way to think about things. And that’s what I’m doing here, and why I’m always explaining what I’m doing, cuz I enjoy watching myself make a fule of myself . I think I’m spiralling into the depths at this point, so I’ll STOP [Stop, Take a breath, Observe, then Proceed] now. so long…

  13. 13
    nrdo

    The story describes a relatively severe case, but there are also people with more moderate conditions who experience plenty of suffering without actually needing inpatient treatment. The horrendous state of the healthcare payment system also prevents these people from getting help in many cases. Based on my personal experience in Canada then in the US, I honestly can’t fathom what someone would do in the US without a very privileged family providing top-shelf insurance.

  14. 14
    astro

    it is not easy to get someone into an IMD or other lockdown facility. “danger to self and to others” is not a magic phrase you can utter to get someone locked up. usually, the first time you call 911, the person having the episode will either have calmed down (e.g., the illegal drugs wore off) or run off, resulting in a visit with no assessment. if there is no assessment, there is no mental health record generated.

    it is only after you establish a history of episodes, that things start happening. the MHP who is handling the file starts showing up with the EMTs. the police stop coming, which usually means that the mental health professional is in charge of the scene.

    eventually, the person will be taken to a hospital, not a jail. the next step is a 72 hour hold. the first few times, the person will be released at exactly 72 hours (which sucks, because most MH calls happen at night, when you can’t try to see a doctor). a few more times, and you finally have a thick enough file for an MHP to support a petition for conservatorship or other proceeding that determines the ill person incompetent, and then you can get semi-permanent confinement.

    oh, and by the way, you can forget about the “and to others” part. that only gets you a brief jail hold. the mental health profession really only focuses on the “danger to self.”

  15. 15
    Crimson Clupeidae

    [Snark]
    A danger to themselves or others?
    …so religion really is a mental illness! (See recent SCOTUS rulings.)

    [/snark]

  16. 16
    Brony

    This is a scary story because I can see parts of myself in there. The last five years shattered my world and I’ve only been able to start to put things back together with professional help the last six months or so. I’ve been pulling away from social contact and the world often just hurts to interact with. Doing anything constructive takes an effort of will and that gets harder when it’s a social situation.

    I know enough about the brain sciences that I recognized the signs for myself and got help. I also force myself to go to meetups and similar, though those social connections feel pretty shallow. It’s all fake right now and I don’t even know what I can rewire when it comes to emotions. But what about people that can’t see the signs and won’t get help? The risks PZ points out are very real and it’s not a big leap to go from things like believing your political opponents are demon possessed to believing they are mentally ill and need “treatment”. I don’t doubt for a minute that there are people in the US that would do what they did to that Nigerian atheist.

  17. 17
    Gorogh, Lounging Peacromancer

    My sympathies, Brony. Hang in there.

  18. 18
    The Vicar (via Freethoughtblogs)

    The article unintentionally raises an interesting question: the man’s illness is severe enough to essentially make him totally dependent on other people — he can’t hold down a job or interact safely with his family — and the rules under current law and society say that the only way to deal with this is to let him deteriorate until he is homeless and in active physical peril. (And, for those who haven’t read the article, it’s not a case of stigmatizing a social misfit; there is evidence that he has genuine delusions and that it responds to treatment. He has been repeatedly tested, and he responded to medication.) So why is the legal standard that his illness is not a “danger to self”? There shouldn’t be any need to abolish patient protections; the man’s predicament certainly sounds like “danger” to me, and it’s certainly based in his mental disorder — he’s going to be homeless and hungry if his parents and ex-wife take the courses of action which are actually recommended to and expected of them.

    Those of you who know more about this subject, is there a good reason why this is the case? Would “there’s a demonstrable problem which responds to treatment and it’s going to put this person on the street, which they don’t actually want, if untreated” be a violation of patient rights if made the standard of “danger to self”? Or is this yet another legal “as long as we pretend there’s no problem, there is no problem” thing?

  19. 19
    pinkboi

    Reading this article, what I see is someone who’s way to optimistic about what they’d be able to do in a hospital. Committing him is not going to magically turn him back into what he was before. And it’s sad that she’s going to deliberately ruin what life he does have to try to make that happen.

    I think most mentally ill people are better off not committed, especially given the conditions in most mental hospitals. If anything, involuntary commitment is still too easy.

  20. 20
    dysomniak "They are unanimous in their hate for me, and I welcome their hatred!"

    So why is the legal standard that his illness is not a “danger to self”? There shouldn’t be any need to abolish patient protections; the man’s predicament certainly sounds like “danger” to me

    Congrats, you’ve inspired me to delurk to say FUCK YOU>. I’ve been diagnosed with depression/bipolar/ADD and could probably qualify for at least a half a dozen others. And I don’t take drugs for any of them. Am I a “danger”? I also ride a bicycle. On the streets! Near cars! Shouldn’t I be locked up to keep me from “endangering” myself?

    Have you ever gone skiing? Swimming? Ever had sex? You’re a danger! Check yourself in to a hospital immediately!

    (Or maybe adults have the right to live their lives however the fuck they want, even if it’s not what you would want.)

  21. 21
    chimera

    What she wishes is that her ex-husband, whom she still loves, could be involuntarily committed to a psychiatric hospital for however long it takes doctors to figure out what’s wrong, for medications to work, and for him to once again be the person she married.

    That’s a quote from the article. It is very wishful thinking. Mental illness is not like strep throat that can usually be cured by swallowing some pills. And no one, not even “normal” people, can become what they once were. Institutionalization and medication are not magic.

    Here’s something I’ve been asking ever since kindergarten (1962) : Why do they want us to be “well-adjusted*”? Why?

    *Term used in the 50s and 60s to describe normalcy.

  22. 22
    The Vicar (via Freethoughtblogs)

    @20, dysomniak

    Congrats, you’ve inspired me to delurk to say FUCK YOU

    Let me congratulate you, in return, for reading my comment without even coming remotely close to seeing the point, and then assuming I was saying almost the opposite of what I actually was saying, and then being rude about it. That’s quite a trifecta. You should be proud.

    If you actually read the article — and I’m betting you didn’t, because you jumped in like that — you would have known that the man’s illness involves delusional behavior and a major disconnect from reality (seriously, read the article — he claimed god was talking through his younger son, he decided once that seeing five bullets at a friend’s house was “a sign” that his 5-member family were all going to be killed, and once ran off with his kids for days without telling his wife where they were going, because he saw a flock of birds flying in a direction and that was “a sign”), and he was surviving only because his parents were giving him food and money — which doctors and lawyers were advising them not to do. His house was being sold out from under him. He’s not “possibly going to become homeless with the illness as an assumed influence”, he’s “definitely going to be homeless with the illness as a direct cause”.

    You aren’t in a situation like the one described. Or if you are, you’re lying about it. Either way, I don’t see that it’s helpful to try and pretend there’s no distinction between someone capable of surviving on their own and someone who simply cannot do so — in fact, it’s actively harmful, because it invites everyone to either overreact to the less-serious case or to refuse to do anything about the more serious one.

  23. 23
    astro

    one of the biggest obstacles to dealing with mental illness is clinging to the hope that it can be cured. it cannot be. it can only be managed.

  24. 24
    zmidponk

    Slightly off-topic, but I did find something a while back that I found quite interesting and disturbing – a video on Youtube that gave a sort of simulation of a typical schizophrenic episode:

    http://www.youtube.com/watch?v=KYHVbLLO2bU

    For best results, listen to it through headphones.

    I also found this, which is also very disturbing. It is a video made by someone who suffers from auditory hallucinations to simulate what they experience. Again, for best results, listen using headphones:

    http://www.youtube.com/watch?v=_oD4QxTjExs

    Having seen/listened to those videos, I can easily see how someone with a mental illness could get confused over what’s real and what’s not, and, because of that, drift away from reality well before becoming a ‘danger to themselves or others’, and be utterly convinced nothing’s wrong.

    And, pinkboi, that’s the issue – because this guy falls short of the criteria for involuntarily committal, the only help available to him is voluntary help, which requires him to ask for it, and he doesn’t ask for it because he thinks there’s absolutely nothing wrong with him. Regardless of whether the family are being over-optimistic about how effective any treatment in mental hospitals would be, it’s better that than getting absolutely no treatment or help at all, which is what he’s currently getting, and will continue to get unless and until he becomes a clear danger to himself or others – and part of the reason that hasn’t happened yet is that his family care about him too much to let him ruin his own life sufficiently that he does become a danger to himself.

  25. 25
    Pazvante Chiorul

    well the problem here is the usa oligarhical capitalistic system itself. The EU,Canada,Australia tend to solve this issue by state owned psychiatric hospital where MOST patients tend to get some form of treatment.”MOST” as in there are abuses but not that many Nevertheless in the united states this would probaly turn into something similar to the private prison industry where cops arrest you and keep you locked up simply so that the private prisons can receive more funds. Similarly I imagine in horror the potential of private medical hospital in lets say the bible belt kidnapping gays,lesbians,artists and anyone undesirable and throwing them in unregulated private mental institutions. I can actually imagine them forcing them to do the conversion therapy thing. Not to mention that commiting someone to a mental facility ruins their reputation and can be used as an easy tool to destroy someone. Scientologists are known for that.Oh btw mental standards are quite lax so th epsychiatric hospitals can easily become psychiatric prisons for the enemys of anyone in power. IF they can’t throw you in jail they’ll throw you in the psyche ward. This is one of those problems i have a feeling the usa will not solve in the coming 50 years.

  26. 26
    pharyngsd

    PZ Meyers

    Keep that in mind next time someone declares that labeling someone “mentally ill” is a good response to a problem.

    Well, “labelling” someone “mentally ill” is not a good response. But recognizing a possible mental illness and therefore follwing up with screening tests for a proper diagnosis is certainly a good response. Especially if the person is exhibiting symptoms severe enough to be debilitating or life threatening.

    In other words, the diagnosis of some kind of “mental illness,” if any, is separate from the “response,” which one could refer to synonymously as the “treatment plan.”

    Wether or not someone follows through on a particular treatment plan is really up to the individual, or the persons responsible for the individual, depending on the severity of the disorder. In any case, having an accurate diagnosis is fundamental to establishing the proper treatment plan.

  27. 27
    Tony! The Queer Shoop

    pharyngsd:

    But recognizing a possible mental illness and therefore follwing up with screening tests for a proper diagnosis is certainly a good response

    And we all know that you’re qualified to recognize and diagnose mental illnesses.

    Please don’t turn this thread into another shining example of your idiocy. The last one was quite enough for a lifetime.

  28. 28
    unclefrogy

    and all of this is from a modern western perspective.
    From my very subjective experience I could agree with what everyone here has said.

    It is absolutely not an either or question. If I had talked about what I was experiencing and thinking at one time I think I would have had some trouble not receiving some involuntary treatment. Which later led me to the opinion that the biggest difference between those diagnosed and those not diagnosed is those who are not diagnosed did not talk about what was going on inside their minds.
    That there are distinctions being made between mental illness and beliefs that may be irrational is important. As our understanding of ourselves expands we see that the different process or functions, the different parts of the physical body and the brain go about to form the mind we are learning how the experiences and beliefs of that mind contribute to that mind and how it perceives reality.

    All of this new growing understanding is in conflict with long held beliefs and practices which is where we are now. Which could be said for much of what we are discovering about “nature” through scientific study.
    How much of this question is really concerned with what is reality and how do we perceive it

    Or how much is this concerned with the question for which the answer is 42.!

    uncle frogy

  29. 29
    pharyngsd

    Tony

    Please don’t turn this thread into another shining example of your idiocy. The last one was quite enough for a lifetime.

    I would have asked the same of you, but it’s too late.

    Your continued proclivity for childish and vulgar insults in response to what should be a normal adult conversation wherein people can actually disagree with one another without sacrificing mutual respect and dignity only deserves one kind of response:

    Piss off, asswipe.

  30. 30
    Azkyroth Drinked the Grammar Too :)

    Your continued proclivity for childish and vulgar insults in response to what should be a normal adult conversation wherein people can actually disagree with one another without sacrificing mutual respect and dignity only deserves one kind of response:

    I’m sorry you’re too fucking stupid to understand what actually makes civility meaningful.

  31. 31
    Tony! The Queer Shoop

    Oh goody. You’ve gotten the hang of vulgarity. I knew you could do it.

  32. 32
    skeptifem

    Dysomniac #20

    Congrats, you’ve inspired me to delurk to say FUCK YOU>. I’ve been diagnosed with depression/bipolar/ADD and could probably qualify for at least a half a dozen others. And I don’t take drugs for any of them. Am I a “danger”? I also ride a bicycle. On the streets! Near cars! Shouldn’t I be locked up to keep me from “endangering” myself?

    Have you ever gone skiing? Swimming? Ever had sex? You’re a danger! Check yourself in to a hospital immediately!

    (Or maybe adults have the right to live their lives however the fuck they want, even if it’s not what you would want.)

    sounds like you are able to function well as a member of society.

    the man in the article can not. That is an important distinction. That is actually a lot of what the DSM and mental health professionals say- the criteria for diagnosis almost always requires the symptoms to interfere with life to such an extent that it causes distress. If you have those symptoms and can still live your life with a reasonable degree of satisfaction then you do not need any treatment.

    I have my own diagnosis (PTSD), but I have also worked in emergency rooms and psych wards. There is a definite spectrum to functioning w/mental illness, and you and I are lucky enough to be able to live outside of supervision or extreme levels of psychoactive drugs. Some people just need a lot of help in order to live meaningful lives. Acknowledging that there are people who definitely need pharmacological or physical intervention doesn’t diminish anyone else. People can accept a spectrum of functioning for virtually any other health problem, why not mental health?

  33. 33
    Tony! The Queer Shoop

    I also note that, once again, pharyngsd makes claims to be able to recognize the mental health of others, despite a lack of qualifications on his part.

    But recognizing a possible mental illness and therefore follwing up with screening tests for a proper diagnosis is certainly a good response.

    Also note that my comment actually had a point, which he refused to address. Just like the thread where he made it all about him.

  34. 34
    skeptifem

    Also, I am a little bit surprised at people here who act as though there are not psych patients who just need the right combo of drugs to return to their pre-illness self. I’ve seen it more times than I can count (bipolar and schitzophrenia are the most common examples, which incidentally use the same drugs for treatment quite often). Sometimes the issue is 100% biological and just needs medicine for treatment. There are other times when medicine solves the issue but therapy is needed to cope with the behaviors that happened before treatment or to adjust to needing to take drugs for a lifetime.

    AGAIN, its a spectrum, but to pretend that this man has no possibility of being helped by psychiatric drugs is ridiculous. It is certainly worth a try.

  35. 35
    Nerd of Redhead, Dances OM Trolls

    But recognizing a possible mental illness and therefore follwing up with screening tests for a proper diagnosis is certainly a good response.

    What Pharyngsd doesn’t get, is that it is nearly impossible to get even a 72 hour exam without the permission of the patient. Nor does the patient have to submit to any examinations once in, or take any drugs, etc. And if they appear to have it together, at least together enough to call a lawyer, they will get out. Of course, with True Believers™, facts are just pesky things that get in the way.

  36. 36
    pharyngsd

    Tony

    I also note that, once again, pharyngsd makes claims to be able to recognize the mental health of others, despite a lack of qualifications on his part.

    I made no such claim.

    When you are trying to discredit me, the least you could do is not make stuff up.

    Also note that my comment actually had a point, which he refused to address

    Who on Earth are you talking to? Do you think there are some kind of “judge panel” that is evaluating the quality of your posts?

    Your initial comment added no value to the discussion at all and was simply an excuse to call me an idiot.

    Why do you insist on picking fights? What exactly is your problem, dude?

    Tim

  37. 37
    pharyngsd

    Nerd

    What Pharyngsd doesn’t get, is that it is nearly impossible to get even a 72 hour exam without the permission of the patient.

    I’m well aware of that.

    No kind of accurate exam is really possible without the cooperation of the patient.

    The purpose of an involuntary psychiatric hold is to make sure no one gets hurt, not to label them as mentally ill.

    I’ve seen *plenty* of patients go to court to argue for their release. It’s a tough argument they have to make…not only do they have to keep their “act together” during their hearing, they also have to defend themselves against the mental health professional that will be submitting evidence (which will almost certainly include the behavior that got them incarcerated in the first place along with everything else they’ve done up to that point) that the judge will certainly weigh heavily.

  38. 38
    Tony! The Queer Shoop

    pharyngsd:

    I made no such claim.

    Perhaps I’m confused and I’m wrong (unlike the time you mischaracterized both myself and Seven of Mine-and never acknowledged-I accept that I can be wrong).

    When PZ said this:

    Keep that in mind next time someone declares that labeling someone “mentally ill” is a good response to a problem.

    You responded with this:

    Well, “labelling” someone “mentally ill” is not a good response. But recognizing a possible mental illness and therefore follwing up with screening tests for a proper diagnosis is certainly a good response. Especially if the person is exhibiting symptoms severe enough to be debilitating or life threatening.

    The first two sentences confused me. Who is the person doing the responding? Is it the person labeling? Or the hypothetical person exhibiting symptoms?

    It’s quite possible that my bias against you colored my interpretation of your comments. Seeing as how it appears I misunderstood you, I apologize.

  39. 39
    Nerd of Redhead, Dances OM Trolls

    The purpose of an involuntary psychiatric hold is to make sure no one gets hurt, not to label them as mentally ill.

    Who doesn’t get hurt? The patient hurting themselves or others? Why should ANY involuntary hold be in place without a prior diagnosis by a trained mental health care professional? Which leaves you and your conclusions where they should be, out in left field.

  40. 40
    karmacat

    Committment laws of people with mental illness vary state to state. I read this article in the Washington Post and believe the man lives in Maryland. In Maryland, you can have a doctor or police emergency petitioned to an ER for a psychiatric evaluation. So a doctor can ask the police to pick up the person to be evaluated. It requires a person to be a danger to himself or others. It can include a person who is not taking care of his basic needs, like eating, being sheltered. To be admitted to the hospital involuntarily, 2 doctors have to agree to this and write why the person is a danger to self or others or is so dysfunctional that the person is a danger to self. The patient then has a meeting with an administrative judge and his doctors. The meeting has to occur within a week of admission. The judge then decides based on evidence whether the patient stays in the hospital or not. In Maryland, a patient can only be forced to take medication if he or she is a danger IN the hospital. This sometimes means a patient can’t leave the hospital but the doctors can’t do anything for the patient.

    It is sometimes hard to find the balance between taking someone’s freedom away (even temporarily) and keeping that person safe. Some patients get better and then stop taking the medicine. Some have suggested outpatient committment, so the person is forced to continue treatment and medication outside of the hospital. Some patients do really need this but it is worrying to take a person’s choices from them. I know of one patient who gets depressed when he is on medicine. So his doctors let him be himself until his psychotic illness leads him to do things like bike around in a short skirt and no underwear and covered in soot

  41. 41
    nrdo

    I don’t know what pharyngsd said in other threads, but it probably would be better if front-line physicians and the general public had a better understanding of the symptoms of mental illness, provided that they also understood that illnesses don’t make people inherently dangerous and that they are variable in degree.

    @ skeptifem

    People can accept a spectrum of functioning for virtually any other health problem, why not mental health?

    This is the crux of the issue. People have trouble understanding it because there is a “moral” aspect to behavior that isn’t present in other medical issues.

    People frame their perception of mental illnesses when the see particularly severe cases, like the one in the article, that have either ended in tragedy or are going without effective treatment. They don’t see the daily struggle and the subtle ups and downs that patients have over their lifetimes.

  42. 42
    cm's changeable moniker (quaint, if not charming)

    Who is the person doing the responding? Is it the person labeling?

    Yes; it’s the poopyhead: right there in the title of the post (italics mine, but given ER context, I think it’s implicit):

    So that’s mental illness

    … and the first sentence of the OP:

    Read this account of a man slipping away into madness.

    If that’s not labelling someone as mentally ill, I fear I may have to consider my English skills kaput and henceforth post only in Esperanto.

    This is not to say that any person described on (or commenting on) the Internet is, isn’t, may, or may not be in any particular mental, emotional, or other psychological state. Neither is it defending, supporting, or even agreeing with random commenters on Pharyngula.

    It’s just reading for comprehension. *grump*

  43. 43
    karmacat

    For someone to be on a psychiatric hold, they need to have a diagnosis of mental illness. You also have to explain how a less restrictive setting would not be appropriate for a patient

  44. 44
    Tony! The Queer Shoop

    cm:
    I’ve responded in the Dome.

  45. 45
    Erlend Meyer

    Problems like this always ends up with interpretations. How can a person in the process of being evicted like this be taking care of his own basic needs? Legally this may not meet the criteria of being a danger to him self, but in reality? Being homeless isn’t a life style choice, it’s an express ticket to an early and wretched end.

    I really hope he gets the help he needs.

  46. 46
    Nerd of Redhead, Dances OM Trolls

    Being homeless isn’t a life style choice, it’s an express ticket to an early and wretched end.

    Some folks prefer to sleep “rough” to being locked up. Are you going to take their choice to do so away from them, legally?

  47. 47
    Erlend Meyer

    I’m not suggesting that these are simple questions, how about you doing the same? Being held hostage to delusions isn’t the same as free choice, that means limiting the scope to only persons that are a threat to others. Basically you’re arguing that insanity doesn’t exist, or at least that there are no such thing as being mentally incompetent. I disagree.

  48. 48
    pharyngsd

    Nerd

    The first two sentences confused me. Who is the person doing the responding? Is it the person labeling? Or the hypothetical person exhibiting symptoms?

    The people responsible or concerned for the individual, or the individual themselves.

    The person exhibiting symptoms are often incapable of making good decisions. They are frequently brought to a psychiatric hospital by the police, in the cases where the symptoms are acute.

    Nerd

    It’s quite possible that my bias against you colored my interpretation of your comments. Seeing as how it appears I misunderstood you, I apologize.

    Accepted. Let’s see if we can figure out a way to have a conversation without pissing each other off.

    Nerd

    Who doesn’t get hurt? The patient hurting themselves or others?

    Both. The “patient,” in the cases of typical suicidal ideation or behaviors, and “others,” in the cases where the patient is acting out violently.

    karmacat

    For someone to be on a psychiatric hold, they need to have a diagnosis of mental illness.

    This is not true in the State of California, at least. As documented in code 5150 (which happens to be the name of a pretty good Van Halen album,) all you need is “probable cause” that they are a danger to themselves or others due to a mental illness, and that’s enough to detain them for up to 72 hours. I think most states in the U.S. have similar provisions.

    FWIW, I spent number of years working in several psychiatric hospitals in the early 80′s. The populations and settings were diverse: adult, adolescent, locked units, open units, acute, chronic, etc. As a “mental health worker” I personally worked on dozens of admissions for individuals under the provisions of 5150. But since it’s been a while, the legal statutes may have changed some. But I don’t think 5150 has changed much:

    http://www.leginfo.ca.gov/cgi-bin/displaycode?section=wic&group=05001-06000&file=5150-5155

  49. 49
    Tony! The Queer Shoop

    pharygnsd:
    Um…that was me, not Nerd.

  50. 50
    Nerd of Redhead, Dances OM Trolls

    But since it’s been a while, the legal statutes may have changed some. But I don’t think 5150 has changed much:

    Actually, things have changed. You can’t hold a person, or jail them, for being homeless. Court decisions. You can’t hold people against their will, if they are capable of expressing it lucidly. Since cutbacks have occurred, there is no room in the psych-ward, so real need, not perceived need is required. Nobody should be held against their will, unless they are a CLEAR danger to themselves and others. Which requires real evaluations, not just a call from the police, or you informal “insights”.

  51. 51
    Deoridhe

    The standards are danger to self, danger to others, or gravely disabled (cannot meet basic needs as is). By far, the holds I’ve been involved in have been gravely disabled because danger to self is usually triggered by the individual on their own and danger to others is …tricky. Unusual. Often, if someone is an actual danger to others, they are functional enough to conceal it.

    Side note on gravely disabled – homelessness is indeed no longer a basis for gravely disabled unless the clinician can make a persuasive argument that the individual would be unable to meet her needs using homeless resources; I approve of the change in standard even if it makes our job harder, because it should be difficult to lock people up against their will. I have also successfully made this argument with clients to whom it applied.

    Things that could help? More beds. By beds I mean not just in locked facilities, like a psychiatric health facility where someone could be on a mental health hold, but also beds at varying levels of support like board and cares (where individuals get room, board, and constant staff presence), structured housing (where individuals get room, support with shopping and cooking for themselves, and regular medication observation), and independent living (where individuals live in the community in public housing and get regular, scheduled home visits with a clinician).

    I work in the last situation, and we have some fairly delusional and yet stable people. I am often far less concerned with how delusional someone is (squirrels tell you to walk on the sidewalk? All good) than what effect their delusions have on their safety (squirrels tell you to walk in the street? Lets talk about reasons to ignore squirrels because walking on the sidewalk is the way to go) and happiness (squirrels tell you that you suck as a human being? I think you’re swell and those squirrels don’t know what they’re talking about), and the extent to which it bars them from doing something (want to swim but afraid of squirrels? Let’s look into non-squirrel routes, or squirrel repellant).

    In my experience, delusions often exist in response to the fabric of a shared reality; they might be about rules to keep one safe, associations gone amuck, or ways of reconciling unwanted feelings and desires. The concept of delusions are often used as a weapon against others – as evidence that they, as a delusional person, should not be taken seriously. This is a problem, both because as a rhetorical technique it’s wanting, and because it contributes to the stigma against people who have delusions but still deserve to be taken seriously and treated well.

    By and large, people currently mentally able think of those with severe mental illnesses as alien and other. They think of them as dismissible and in need of being told what to do. They think of them as agencyless and lacking in intelligence and informed opinions. All of this contributes to a climate in which they are treated more poorly, learn to expect it, and do the best they can with limited resources and a system which is constantly changing and perpetually underfunded.

  52. 52
    pharyngsd

    Tony

    Um…that was me, not Nerd.

    Whoops. Roger that.

    Sorry about that Nerd.

    Nerd

    Which requires real evaluations, not just a call from the police, or you informal “insights”.

    The link I provided was to a California government sponsored document. It’s from a website for “Official California Legislative Information.” Probable cause for a mental disorder (from a peace officer, professional person in charge of a facility designated by the county for evaluation and treatment, member of the attending staff, as defined by regulation, of a facility designated by the county for evaluation and treatment, designated members of a mobile crisis team, or professional person designated by the county…) is the only required standard to place a 72 hour hold due to “danger to self or others, or gravely disabled.”

    It’s not my informal insights at all.

    Back in the day, and I doubt that much has changed when 5150 is applied now, (the document itself doesn’t seem to have changed appreciably from the way I remember it,) the police would phone ahead that they were brining someone in, just to make sure we had room. (The hospitals I worked at were private, and were often used for overflow for the County hospitals.) There was no other evaluation required at all. The person was literally transported in the back of a patrol car and incarcerated on the authority of the cop. We would then admit the patient, process them according to the requirements of the 5150, which included reading them their rights and giving them additional written documentation, and that was that.

    Of course, the hospital could object to the admission, since the Police could abuse their authority and dump an actual criminal into the mental health system to essentially wash their hands of a problem, but I can’t think of a single instance where that actually happened on my watch. But I’m sure it happened from time to time.

  53. 53
    Quotidian

    That was haunting. As someone with a mental illness (MDD and dysthymia, lucky me) I always appreciate when people with a platform spread awareness.

    Actually this brings up a lot of stuff for me. I live in the US, and I’m lucky enough to be both young and with well off parents, so I could use their (really good) insurance to get treatment in an inpatient facility. Which I desperately needed because, you know, wanting to die all the time and trying to kill myself weren’t exactly signs of a healthy mind. I’m incredibly thankful that I’m doing much better now, thanks to therapy and an endless litany of medications, but I’ll always think of something my parents said when we were trying to sort out payment:

    Mom: “This is so expensive! What do you do if you don’t have insurance?”
    Dad: “You pay out of pocket.”
    Mom: “And what if you don’t have a hundred thousand dollars lying around?”
    Me: “Then you die.”

    When talking about mental illness, the problem of getting people who don’t want treatment to get it is important, but the problem of people who want treatment and can’t get it is also huge. It speaks to the fucked-up-edness of our current healthcare provision “system” that my family would be bankrupt without my father’s job’s insurance. That’s something that needs fixing, pronto.

    @Brony, #16: Your experience sounds awfully familiar to me. Hang in there friend. It’s rough going at first but there’s a lot in life worth living for.

    You know, your experience also sounds awfully familiar to a guy I know in the fandom. The author of a certain epic length fanfic. You wouldn’t happen to know him, would you?

  54. 54
    Giliell, professional cynic -Ilk-

    First of all, let me congratulate you PZ for always poting these kind of articles when they really, really, really hit home (no, not really your fault. Just cosmic coincidence cruelty)

    And now:
    This is damn complicated

    1. Diagnosis
    They are not a hard on/off thing. Let’s not kid us, you cannot diagnose mental illnesses or disorders like you can meassure the Ph of water. I was in therapy for more than 2 years, but I was never diagnosed with anything. The reason? This therapy was provided via the student services at college. Their rules and regulations are different, so all my therapist had to do was to justify my need for therapy according to their rules and when we went past the usual 25 sessions they provide he could just get an extension. For somebody out there to provide the same treatment they would have had to diagnose me with something and then apply for treatment with that diagnosis.
    The difference between a diagnosis or not was not in me and my mental health but in regulations.
    Same with my daughter’s autism diagnosis: The psychologist would have preferred to label it “probable”, but that wouldn’t have gotten us anywhere when trying to get help.

    2. I totally understand the family who wants him to be committed. Been there, done that. I once spent half a night searching for my cousin who had slipped out of the open psychiatric ward while we were all afraid for his life and that of others. Police (Germany) told us more or less the same as those in Maryland apparently do: No involuntary commitment, no obvious danger, no way. They would keep their eyes open, but as long as he didn’t do anything to draw their attention it was more than improbable .
    And just this week I talked to a paramedic about whether it would do good to call the police on a different family member. You’re helpless and you want to do something.

    3. I think the family in the article still hasn’t realized that they cannot do anything, that the only person who can do something is he himself. It’s a hard lesson to learn. The advice from his former psychiatrist sounds very much like the advice we got time after time again: Stop supporting them. They are loving, they are caring, and they are also enableing him. It’s like buying an addict their drug because you don’t want them to suffer from withdrawl while still hoping every day that they will say “no thank you, today I’m going to a clinic to get a substitute”. It is not going to happen. Many people need to be really, really low before they are able to change something. That’s not unique to people with mental illness. How many of us (with health insurance) have turned up at the doctor’s two days after we should have reasonably gone there? Postponed dental appointments until it hurt?

    4. Another question neither the family nor those in favour of easier involuntary commitment have answered is this: What good will it do? Yes, it will keep this man off the street, which might actually be the thing he needs in order to be able to seek help. He will be locked up against his will and know this every single minute. Does anybody actually believe that this will make him cooperative and willing to get treatment by the people who actually mistreat him every single minute. As I said, I understand the wish, but I also know that it would not help. That’s probably the biggest problem of his family: They still believe that somebody can help him whether he wants or not. Somebody can fix this problem if only the government allows that person to treat him without his consent. Not going to happen.

  55. 55
    Louis

    Oh sweet suffering unholy fuck. I see the Clueless Stigmatisers are out in force again. Well, I suppose it could have been a useful conversation about the perils of blanket regulations, the difficulties of involuntary “institutionalisation”. These things are possible.

    PZ, I’ll reiterate that my earlier, original criticism of you on this issue is retracted. Several subsequent posts have indicated clearly that you get it (how could I have doubted that… tsk. Such terrifying lack of worship by a Pharyngulite. What will the pitters say?). Thanks for this post.

    Personally, I found the article to be a terrifying appeal for easier institutionalisation, or “sectioning”/”detaining”* as we UKistas would call it. It’s one of those things that is incredibly hard to legislate for. For exactly the reasons (historical misuse, ease of misuse, current misuse etc) you highlight. It’s also absolutely essential for someone’s care when they have lost insight (in the strict psychiatric/psychological sense) into their behaviour/situation/condition to a sufficient degree that treatment is necessary.

    It’s one of the most hotly debated and controversial things in mental health, along with restraint when detained/sectioned/involuntarily institutionalised. It’s also one area where the simplest description is that there is no right answer at all. For example, in my volunteer work I deal with quite a few people who have been sectioned, and a good portion of those have experienced physical restraint etc. Rarely have I heard more traumatic stories. More than a few of the people I’ve spoken to describe it as the worst violation they’ve experienced and no small percentage of those people have plenty of other things to compare it to.

    Part of the problem lies in what I described earlier: lack of insight. When you’re bouncing off the walls manic and hallucinating quite wonderful things (for example), you’re not ill. Not as far as you’re concerned. When the police, members of your family, an ambulance, a doctor (maybe two) show up and attempt to cart you off for assessment this is an intensely traumatising experience. The clinical picture of how effective involuntary detention is is {haha} complicated.

    For me, at least, the really interesting part of this is the efficacy of detainment as a medical intervention. There are, of course, unambiguous cases where such interventions are matters of triage, or of absolute necessity in the short term health of the person suffering from the mental illness. These are, perhaps counterintuitively, rarer than people might think. Except in extremis it is usually possible to get someone to agree to some form of treatment/help/intervention, i.e. for them to demonstrate some small degree of insight (at the very least). Naturally, there are exceptions, and the worsening case of the gentleman in the article may be one example (obviously I am not a) a physician, or b) HIS physician, so it ain’t for me to say) where there is clear enough lack of insight to warrant detention, and such detention would be medically productive. It may not be. After all, we’re getting “facts” from an article that very clearly has an agenda.

    Back to the res, efficacy.

    Here’s a few links to Cochrane and other places for those interested. Again, with my standard caveat on these matters that such links are a place to BEGIN investigation, not end it so pronouncements of X or Y or reinforcement of pre-existing opinions can be made. I’m looking at the Clueless Stigmatisers in particular. Link 1, Link 2, Link 3. Given the linking restrictions, I’ll stick a few more in a comment below.

    The trend away from detention and towards community based interventions, outpatient interventions etc has seen an improvement in certain health outcomes (see above), but again, it’s not a simple picture. My fear is that societies will yo-yo back to varying degrees of “lock ‘em up”, tracking conservative/reactionary political trends and decreasing desires to make evidence based policy. After all, this is the case in so many areas, why not here too. That’s not to say there is no place for involuntary detainment as a medical intervention, there undeniably is, but as highlighted in the OP, it’s not something that should be considered as lightly or paternalistically as it has been in the past.

    Louis

    * For contrast/comparison the Pfft has the beginnings of a description.

  56. 56
    Louis

    MOAR LYNX!

    And a one, and a two, and a (pdf) one, two, three four. Enjoy!

    Louis

  57. 57
    Joe O

    I found this really interesting. I live in Maryland and have been committed three times. They were all voluntary, though two of the times i was in a hospital bed after ODing on my medication and the doctor told me if I didn’t agree to voluntary commitment he would get a judge to order an involuntary one. I’m bipolar by the way. Each time I spent about 5 days committed. Most of the people there seemed roughly like me and were in due to stuff like depression. At one of the places we share the ward with people trying to quit addictions. At another place there were a couple of people who had somewhat more severe issues and occasionally had outbursts and had to be temporarily moved to a locked, padded room. Most of the time there we other talked in groups, made crafts, or listened to new agey relaxing music.

    I certainly don’t feel like this makes me an expert on diagnosing other people as mentally ill but there are times when someone’s behavior reminds me of what I was like when I was manic (which is a whole crazy other story) and then I don’t have a problem saying to myself “I think that person may be mentally ill and should definitely see a professional. I feel that if anything that’s being more sympathetic to them. For example I remember during the whole Charlie Sheen episode it reminded me of a classic manic episode. I had the same feelings of invincibility and grandiose delusions. I also have a Facebook friend who I only ever knew online that will go for weeks at a time making all sorts of incoherent comments about various other people we knew online years ago being fakes and out to get him and it definitely seems like he’s off his meds.

    I guess I feel that while it’s irresponsible to try to diagnose someone with a mental illness if you aren’t a doctor, it’s ok to suspect one if you’re legitimately concerned about them and want to try to find a way for them to get help.

  58. 58
    pharyngsd

    Joe O

    I guess I feel that while it’s irresponsible to try to diagnose someone with a mental illness if you aren’t a doctor, it’s ok to suspect one if you’re legitimately concerned about them and want to try to find a way for them to get help.

    This.

    It’s really no different than suspecting that someone you care about has a serious medical condition. There shouldn’t be any “stigma” about it at all.

  59. 59
    Brony

    @ Quotidian 53

    @Brony, #16: Your experience sounds awfully familiar to me. Hang in there friend. It’s rough going at first but there’s a lot in life worth living for.

    You know, your experience also sounds awfully familiar to a guy I know in the fandom. The author of a certain epic length fanfic. You wouldn’t happen to know him, would you?

    No. My claim to fame in the fandom is that I was a moderator of the serious discussion forum on one of the image boards. I’m technically still a moderator but I’m taking an extended break because the things I am working on with my psychologist and my natural weaknesses due to my own mental issues don’t combine well when it comes to breaking up fights in a community. I essentially lost my science career from undiagnosed and untreated TS+ADHD and it’s a thing that has had a more severe effect on me than I thought it would.
    Frankly the social issues related to Tourette’s leave me astounded that I even considered the position, apparently social stress may be the number one factor that creates stress in people with TS and combined with the social deficits, I’m just not sure what to do there.
    I was hired because I’m pretty “OCD” (perhaps literally) when it comes to fact claims and serious discussion and my science experience and experience with creationists made me an excellent balance against the more aggressive assholes “discussing” things like the more stereotypical libertarians essentially assaulting people that wanted to discuss socialism and communism (sometimes by literally characterizing people actually living in communist or socialist countries as literal murderers because they were socialists or communists), or the usual utterly dishonest portrayals of political and philosophical groups that many have a group-oriented hatred for. Between FTB and the Brony community I got to experience two schisms. Fascinating but very intense and stressful.

  60. 60
    Psychotic Atheist

    Full diagnoses are only for the benefit of insurance companies – ie schizophrenia or depression etc. Sometimes it makes people feel better to have a name for their illness, but the fact is it’s almost entirely arbitrary names for suites of symptoms. You can’t diagnose someone with schizophrenia before involuntarily committing them – because the old DSM requires symptoms be present for months at a time. You could diagnose them (possibly) with psychosis within one interview (with cooperation).

    As to PZs post, it hits a nail on the head. Mental illness is insidious. With me I came close to starving, I dropped out of university and was weeks away from homelessness and still nobody in my life noticed I was having a psychotic episode – and it wasn’t the first episode either. My current wife was the first to notice, but only after a year or two and she only thought something wasn’t quite right.

    I recognize much of ‘yellow door’ in myself. Although my psychiatrist resisted actually diagnosing specific illnesses (primarily talking about symptoms and how to cope with them) if I was to self diagnose I probably would put myself somewhere close to “a schizoaffective disorder, depressive type with persecutory delusions.” For me, anxiety leads to paranoia, paranoia leads to psychosis, psychosis leads to despair, despair takes me around to anxiety and so on. There are only two symptoms I still haven’t got a way of properly dealing with and cause significant problems in my life: anhedonia and the social withdrawal.

    I don’t know the details, and having children is certainly a complication, but ‘Jennifer’ is complaining that state is abandoning him by not forcefully removing his freedom and forcefully medicating him. This might of course miraculously cure her husband, if the whole of the problem is simple like a dopamine deficiency.

    But being taken to an institution and held against my will? I’m pretty sure that would make me dangerous, not cure me of my paranoia. I’m sure it would not help yellow door with his persecutory delusions’.

    By all accounts, other than family tensions, it seems Yellow Door is functioning (tidy house, a desire to remain in contact with his children etc). He says he is not ‘sick’ and if he is simply mentally ‘abnormal’ but is not suffering, then that makes sense as a thing to say. I’m not sick, either. My madness has certainly caused a relationship breakdown or two in my life, but it’s also part of who I am. If other people couldn’t live with me, I’d happily (to a certain extent) live alone rather than being ‘brainwashed’ by ‘white coats’ into being a ‘norm’.

    It’s a difficult line, of course. Too many people quietly do fall into the homelessness that I was fortunate to avoid (fortunate in that I was able to live rent free by being a dreadful tenant with a relatively kind landlord (who incidentally, was paranoid schizophrenic)), and society needs to find a way to answer the moral questions it raises. If they are happy as they are or refuse consent, at what point can we ignore this?

    The real problem is that there isn’t a cure in any event. Certain drugs can help certain symptoms. In psychosis we might be freed of the worst of the hallucinations and delusions through anti-psychotics. But dealing with negative symptoms (anhedonia, amotivation, reduced affect etc) is much less easy. Good luck motivating someone who barely registers happiness and whose emotional state cannot be inferred from their tone of voice.

    And since mental healthcare funding is often on the list of ‘things we can cut that few people will notice or care sufficiently about’, I don’t see the State’s moral decision making to change (in the long term towards mental heath welfare) any time soon.

  61. 61
    pharyngsd

    Psychotic Atheist

    If they are happy as they are or refuse consent, at what point can we ignore this?

    Tough question. Especially in the U.S. where there are fierce protections of individual liberty.

    In extreme cases, a person can be deemed “legally incapacitated” and would be assigned a guardian or a conservator, depending. The guardian can then force treatment.

    I think if someone is unable to provide for their own food, clothing and shelter (because of a mental illness) they have reached a point where the State can step in and force treatment. But even if that were to make some sense, it only addresses the acute phases. What about the other times when the person is functioning fairly well and then refuses treatment, thereby initiating another acute phase?

    Balancing the rights of the individual with the practical needs of the State while trying to mitigate the pain and suffering endured by family and other loved ones….it’s a tough, tough, problem.

    Incidentally, regarding the overall insidiousness of mental illness. I would strongly recommend “The Eden Express” to anyone that is interested in getting a first hand view of what it’s like to experience acute mental illness. It’s written by Mark Vonnegut, son of Kurt Vonnegut, Jr, and covers his own experiences when suffering multiple psychotic episodes. And while their may be no cure, per se, Mark ended up going to Harvard Medical School and became a Pediatrician. One can cope.

    There is a recent interview with him here:

    http://www.smithmag.net/memoirville/2010/10/19/interview-mark-vonnegut-md-author-of-just-like-someone-without-mental-illness-only-more-so/

  62. 62
    Psychotic Atheist

    @pharyngsd

    Indeed – I have recently returned to University to finish my degree, and have landed a ‘dream job’ and am episode free for about 3 months. For some that may never be possible, but in almost all cases it is possible to build at least a tolerable life. Heck, if you’re lucky you might even win a Nobel, right?

  63. 63
    chigau (違う)

    pharyngsd
    I think if someone is unable to provide for their own food, clothing and shelter (because of a mental illness) they have reached a point where the State can step in and force treatment.
    or maybe the State could step in and provide food, clothing and shelter.

  64. 64
    Arawhon, a Strawberry Margarita

    pharyngsd @61

    I think if someone is unable to provide for their own food, clothing and shelter (because of a mental illness) they have reached a point where the State can step in and force treatment.

    Welcome to my life. Due to my mental illnesses, I cant provide for food, shelter, or housing since I cant get a job. Without the state giving me housing, food stamps, and my family providing a small pittance for clothing and other items, I would be on the streets. What you are advocating is for tens of thousands of individuals, most being homeless, to be locked up in mental wards away from polite society. Your position is sickening and irresponsible.

  65. 65
    ck

    pharyngsd wrote:

    Tough question. Especially in the U.S. where there are fierce protections of individual liberty.

    <cynical>As long as that individual liberty doesn’t include bodily autonomy. The U.S. happily violates that one for any damn fickle reason. It ranges from force feeding of prisoners (usually to break hunger strikes) to invasive bodily searches for contraband (including repeated enemas delivered by doctors) or ignoring “do not resuscitate” instructions in hospitals to cosmetic surgery done on infants to prohibitions against abortion.

    Maybe someday America will live up to the ideals it claims to cherish.</cynical>

  66. 66
  67. 67
    The Vicar (via Freethoughtblogs)

    @60, Psychotic Atheist

    By all accounts, other than family tensions, it seems Yellow Door is functioning (tidy house, a desire to remain in contact with his children etc).

    Wait wait wait… he can’t hold down a job, he’s losing (actually, since the article is in the past, he probably has already lost) his house*, he was surviving only because his parents were giving him money and food… how is that “functioning”? The house was only “tidy” from the outside, if you read, and then really only in the sense that he was mowing the lawn; the article mentions that he had partially — but only partially — spraypainted the garage door with yellow paint. The inside was full of disassembled machinery and furniture and full garbage bags. That’s not “tidy”.

    *Incidentally, I wonder what the disclosure laws are for house sales in Maryland. “Oh, yes, [prospective buter], this house was last lived in by a guy who had psychotic episodes and disappeared off and on, all the partial yellow paint and loose bits and pieces of machines are left over from what he was doing here all by himself for months and months and months, and we’re not sure whether he truly grasps that the house no longer belongs to him, so he may show up and try to get in. We can’t check, because nobody knows where he is right now. Oh, and he once made some remarks which sounded ominously like he was thinking about committing murder-suicide with his family. Don’t worry, though — the court didn’t consider that sufficient evidence that he was a danger to others, and besides, it’s been so long that if he’s still alive at all, he’s probably absolutely desperate. So, ah, want to put down a deposit?” That’s not a sales pitch, that’s the prologue to a bad horror film.

    He says he is not ‘sick’ and if he is simply mentally ‘abnormal’ but is not suffering, then that makes sense as a thing to say.

    Well, great! The Republicans tell us they aren’t racist, either — I guess that means there’s nothing to worry about there.

    I repeat: this guy is on track to become homeless and starving. Are you seriously categorizing that status as “not suffering”? The only thing which seems to be standing in the way of that is if his wife and parents sacrifice their time and savings to keep him going — are you saying that the family of people with mental disabilities should be required to provide support, but should not have the right to ensure that the disabilities are being dealt with in any way?

  68. 68
    pharyngsd

    Arawhon

    What you are advocating is for tens of thousands of individuals, most being homeless, to be locked up in mental wards away from polite society.

    Please don’t assume the worst. That is most certainly *not* what I am advocating.

    When I say “treatment,” I mean “humane treatment” that would (hopefully) reduce the likelihood that they would have to be locked up in mental wards away from “polite society,” as you call it.

    If effective treatment exists for mental illness, and I realize that’s a big “if,” at what point does an individual lose their right to refuse the treatment?

  69. 69
    Gen, Uppity Ingrate and Ilk

    If effective treatment exists for mental illness, and I realize that’s a big “if,” at what point does an individual lose their right to refuse the treatment?

    You see, there’s a huge problem here, and it ain’t even your “if”. What the hell does “effective treatment” mean, and what if the patient would literally rather die than undergo said treatment?

    Like I’m bipolar II and sometimes I get horribly depressed. Electro-convulsive therapy is said to help with that. Yet I would literally rather kill myself than go through it, and I’m talking rational, well-functioning, non-depressed “me”. I would never even consider it, even as a last-ditch option, even if all the meds in all the world and all the therapy and everything else had failed (yes, I think about this a lot).

    So how do you force something like that on a patient who so very much doesn’t want it that forcing it will only create more trauma and further exacerbation of the existing illness? I don’t think there’s ANY time when you can morally do that.

  70. 70
    Giliell, professional cynic -Ilk-

    psychotic atheist

    By all accounts, other than family tensions, it seems Yellow Door is functioning (tidy house, a desire to remain in contact with his children etc)

    Not really. His family keeps him functioning by providing food and money and transportation for him.

    pharyngsed

    If effective treatment exists for mental illness, and I realize that’s a big “if,” at what point does an individual lose their right to refuse the treatment?

    How effective do you think yould treatment be that is undertaken AGAINST the will of the patient? And we’re not talking about making somebody take antibiotics for a week. We’re talking about something that takes months to years to a life long dependency on medication. Really, even if the question of rights was sorted out, the question of efficiency has already been answered.

  71. 71
    Psychotic Atheist

    @Giliell
    He’s clearly a dependent, but I wouldn’t argue that means he isn’t functioning. Obviously his illness has had a profound impact on his life.

  72. 72
    ledasmom

    pharyngsd:

    If effective treatment exists for mental illness, and I realize that’s a big “if,” at what point does an individual lose their right to refuse the treatment?

    As has been ably pointed out at #69 above, that which may appear to the one who is not being treated as good and effective and humane treatment may be nothing of the sort to the one under treatment. I have anxiety. It causes immense problems in my life. I was recently on Celexa for said anxiety, which did indeed remove the anxiety; it was in that sense effective. However, I was so drowsy I would come home from work and fall asleep; worse, I was mentally muffled. Therefore, no more Celexa. I would rather live with the anxiety spirals than the near-complete lack of mental and physical energy. But there is no doubt I am a more pleasant person when on it. The trouble is that by “effective” I mean something that makes me more generally functional, not less.

  73. 73
    Giliell, professional cynic -Ilk-

    Psychotic Atheist

    He’s clearly a dependent, but I wouldn’t argue that means he isn’t functioning. Obviously his illness has had a profound impact on his life.

    I’m not sure, but it is too much speculation about an individual right now. After all, all we have are third person perspectives on him.
    Yet I know that for many people who actually need treatment the fact they are able to do simple things like buying food gives them the illusion of being in control and functioning.

  74. 74
    pharyngsd

    ledasmom

    As has been ably pointed out at #69 above, that which may appear to the one who is not being treated as good and effective and humane treatment may be nothing of the sort to the one under treatment.

    I know. When I worked in psychiatric hospitals, the side effects of the meds were often dramatic. Patients would take Artane to reduce the side effects of their meds and then need other medication to reduce the side effects of Artane. It was pretty tragic.

    Many of the patients I talked to reported that their meds left them feeling *nothing.* (Others said that it gave them a “buzz” that they actually enjoyed…) That’s why they wanted to cut back, often with disastrous results. They would start to feel again, but then “feeling good” would transition to “euphoria” and then they would *really* start to lose their inhibitions, refuse all meds and have another break. As horrible as it was to watch, I can’t imagine what it’s like to actually go through it.

    So what’s the alternative?

    Even in traditional medicine, there are side effects to life saving procedures and medications. My wife had to go on a blood thinner after having a stent inserted into her heart. The blood thinner has a lot of risks. She could literally bleed out if she were to have what would normally be a trivial accident. (Falling off her bike, accidentally cutting herself with a knife, etc.)

    Certainly no one likes the side effects of chemotherapy, either. I might rather choose death than undergo chemotherapy, depending on the survival rate of the cancer.

    Under normal circumstances, it’s up to the individual to decide whether or not a particular treatment is worth the risks.

    But is a chronic condition that creates habitual dependencies, dangerous situations, and a severe lack of judgement for the individual a normal circumstance?

    Gen

    How effective do you think yould treatment be that is undertaken AGAINST the will of the patient?

    It depends. I’ve seen ECT combined with a drug regimen have near miracle effects on some extremely psychotic people. But my experience is purely anecdotal. However, I would wager that studies are available that demonstrate the efficacy of meds to reduce the severity and duration of a psychotic episode. How effective they are long term…that’s another question. Isn’t Lithium is pretty well established as a “cure,” more or less, for many people suffering from bipolar disorders?

  75. 75
    The Vicar (via Freethoughtblogs)

    @71, Psychotic Atheist

    He’s clearly a dependent, but I wouldn’t argue that means he isn’t functioning. Obviously his illness has had a profound impact on his life.

    So, what’s your solution, then? For his wife and parents to go on supporting him — with no say in how he lives his life and no ability to demand that he seeks treatment for his problems — until they die, go bankrupt, or both? What about their autonomy? They didn’t ask for this situation either, but you seem to be arguing that as many consequences of the man’s illness should be visited on them as possible.

  76. 76
    Psychotic Atheist

    @73
    Requiring treatment doesn’t mean you aren’t functioning.

    @75
    There is no correct or perfect solution. If I had one, you probably wouldn’t hear about it from me in a comments section – it’d be on my wiki page or something.

    In any event, I make no demand or argument as to what the wife and parents should be doing. There are many people in the world who are, without choice, compelled by compassion or a sense of duty into becoming carers for people whether it be elderly parents, addicted siblings, becoming a parent, or sudden illness somewhere in the family (mental or physical).

    The choices seem to be:
    1) Leave them be and let Darwinistic processes sort things out
    2) Family/friends supports them where there is one
    3) Charity provides support
    4) State provides support

    Personally, I think the government should provide financial support to carers and charities should provide occasional relief to people who are full-time carers.

    If a loved one falls ill, we have to make a moral choice how we ourselves are going to handle this. I don’t think involuntary incarceration should be the first choice, for most cases, any more than involuntary surgery is the default action where it is in the best interests of the belligerent individual. Likewise, however, an argument can be made for certain cases (just as with children, or mentally challenged individuals may have the state step in to make medical decisions).

    I have no idea how the US mental health system works, but I’m guessing it is built on a cold (and green) foundation. In the UK, which is not being held up as a paragon, getting ‘sectioned’ (stemming from ‘you are being detained under section x of the mental health act’) is rare and patients do have rights of appeal and in most cases, the right to choose or refuse treatment options. You can even be ‘released into the community’ on certain conditions and you will be provided with free aftercare after being discharged.

    Carer’s are entitled to a Carer’s Allowance, and sufferers can apply for Personal Independence Payment and/or Disability Living Allowance.

    The payments are terribly small, but the principle seems sound and it does help allow people a sense of independence even if they are technically dependent.

    In short: the situation sucks and there isn’t a good solution. We just have to struggle our way towards achieving the best solution we have available. I don’t even claim to know the latter, but have highlighted some elements thereof that might be illuminating as to my personal opinions, since you elicited.

  77. 77
    The Vicar (via Freethoughtblogs)

    @76, Psychotic Atheist

    I have no idea how the US mental health system works, but I’m guessing it is built on a cold (and green) foundation.

    Well, there’s the problem. You have effectively no clue about this case, the relevant law, or the surrounding culture. No wonder you keep taking untenable positions.

    There is a disability system in the U.S., but if you are an adult and not considered irresponsible to the point where someone else has charge of you, then you are responsible for getting on it. It provides very little, and almost anything will kick you back out of the system — both the major parties approach public aid these days from the perspective of “we have to make this as difficult as possible to use, or else there might be people abusing it” rather than “we have to make this accessible, or else people who need help might not get it”.

    Basically: this guy is unable to even start the process of getting public aid. He has paranoid delusions, he disappears sometimes, and he can’t write capably any more. The same issues which keep him from getting a job keep him from getting aid which he needs in order to survive without a job.

    Of course, if he had a guardian to apply for the benefits on his behalf, that would work — but said guardian would necessarily also have the privilege of insisting that he seek treatment. (Depending on the specific state law, it might even be a requirement of applying for aid.)

    Under current law in Maryland, as outlined in the article, nobody in the family can hold that kind of guardianship until/unless the guy either tries to commit suicide or tries to kill some other person. Basically, the family is put in the position of being forced to hope that he will make that kind of attempt, because they can’t do anything at all to stop him from a gradual, practically-suicide death unless he does.

    This is, in fact, where you and I (and, perhaps more relevantly, the state of Maryland and I) part terms. To me, if someone has a mental illness which involves psychotic delusions and it’s going to make them homeless and starving, it means by definition that their state of mind is self-destructive, they aren’t responsible, and they need someone to have authority over them.

    “But” you (and a few others above) say, “you can’t be certain that a treatment would be 100% effective! So he shouldn’t be forced into treatment!”

    There’s old comic about how people don’t take mental illness as seriously as they take physical illness. In this case, thank goodness we don’t! If this attitude were applied to physical illness, we’d hear things like “we can’t be certain that you’d be able to keep your blood sugar down, so we’re not going to treat your diabetes even though you have a blood sugar reading of 450. Good luck not slipping into a hyperglycemic coma! Hope everything works out for you!”

    Someone who is having delusions really is not in the same category as someone who is depressed; they need intervention. Denying it to them is not giving them some kind of “freedom” any more than foreclosing on a 90-year-old’s house and kicking them out into the snow is giving them “freedom”. If the only realistic “choice” someone has is to die, then they don’t have a choice at all.

Leave a Reply