Forcing someone to undergo potentially mind-altering medical treatment (because they absolutely will drug someone who fights against being there) and probably abuse (just check the stats) at the hands of the system isn’t humanitarian either.
This is one of those situations where all you can really do is make sure the options are as good as they can be, so people want to choose to get help, and we are not even remotely doing that.
Severely mentally ill people don’t want to choose help, that’s a function of being severely mentally ill. Leaving the decision making to people fundamentally incapable of making a decision actively harms them.
If the system was actually helpful to people, and severely ill patients still didn’t want help, you might have a point. Right now though, the system doesn’t help most people, it harms them actively, so we don’t actually know how many people would still refuse quality care.
And let’s be serious here, the number of people so mentally ill they can’t be trusted to make a decision about whether or not to take offered help…? Really really small percentage. We definitely shouldn’t be structuring the entire system based on edge cases, even if those edge cases have a legitimate need for that sort of inhumane treatment (a premise I strongly question).
Yes, however it’s mostly a refutation to your prior comment that severely mentally ill people refuse treatment as a direct consequence of being mentally ill. This is only rarely the case. The vast majority of those severely mentally ill people are still people capable of learning about stuff and doing cost-benefit analysis for their own lives. They make rational decisions to the best of their ability. This ability may be flawed, but that’s the case for all people. Nobody has a pure, 100% complete and accurate view of things.
They refuse treatment largely because the system is horrible. Would they still refuse if the system wasn’t horrible? Most of them probably would not, because struggling is really hard. Most of them would get themselves the help they feel they need if they honestly thought there would be a good outcome.
But what they think they need and what the system or society thinks they need aren’t necessarily the same thing. Maybe all they really -need- is a place to exist exactly as they are, with zero medical intervention, with a clean environment where they feel safe and secure. If that’s all you felt you needed, would you risk being drugged for the rest of your life? I sure as hell wouldn’t, no matter how bad my experience of existence is. At least I have agency.
And honestly until we reach that point, where mental healthcare is supportive to the individual and genuinely helps them live whatever they feel is a fulfilling life, discussing what to do with the minuscule remaining fraction of sufferers (a number we genuinely can’t even quantify at this point) is sort of dumb, and seems like a pretty big distraction from doing anything better for everyone who isn’t in that camp.
They percieve the system as being horrible, but again, that’s a function of their mental illness.
The system does have problems, but there’s no refuting the fact that whatever problems the system has, it’s infinitely better than an amputee with an infected leg sitting in the dirt with no shelter.
I personally would rather be an amputee on the side of the road with no shelter than be kept prisoner in my own body with the use of drugs and restraints. That’s literally my worst nightmare. And I’m not “severely mentally ill”.
You don’t know what reasons she has for doing what she does, but what IS completely, abundantly, crystal clear, is that she herself considers the position she is presently in to be better than whatever she would potentially deal with under care. And you don’t know why she came to this conclusion. Maybe she was institutionalized when she was young and was abused or whatever and has ptsd about it. Maybe she knows someone else who was.
Or yeah, maybe she’s so mentally ill that it’s forcing her to deny care. I strongly doubt it, but maybe. And we’ll never know unless we fix everything else first. So. Kinda moot point, isn’t it?
That’s still better than letting an amputee sit in the dirt, feet away from freeway traffic, unprotected in 100° heat.
At some point there needs to be a competency hearing and the person cared for even if they can’t or won’t ask for it. ESPECIALLY if they can’t or won’t ask for it.
The alternative is going “Welp, too bad they died, nothing we could do.”
This is something you and I aren’t going to agree on. From my perspective its an issue of consent. From yours (it seems) and issue of wellbeing. Our heirarchies of needs seem to value personal agency at different levels. I consider it to be a core need, and from that perspective I would never (given the power to do so) exert my will to care for someone as a ward of the state or whatever org I represent without the consent of the individual to be cared for.
I also recognize what you’re saying, that at a certain level of incompetence a person should no longer be able to advocate for themselves and should be required to accept care.
I personally believe that if a person can communicate, they can communicate consent. If a person is completely unable to communicate, it may be a good idea to give them a period of investigative and protective custody to determine their safety, but from their perspective that could be a kidnapping.
I’m not saying your perspective is wrong, but this is a situation that needs to be handled with extreme nuance and care by professionals.
On competency evaluations:
I’d need a large panel of Psyches from the same and similar communit(y/ies) as the JD (john doe/ jane doe) to all agree they are incompetent before I’d be comfortable allowing their consent to be violated in the manner of state endorsed internment in medical or mental facilities. If the medical community agrees, and the people around the JD agree, then and only then should the JD be given care without their consent.
I think the difference in our opinions are less than you think it is, you argue from a point of personal autonomy, and I get that, my argument is they have already lost their autonomy due to mental illness.
So if they have no autonomy already, society needs to error on the side of making sure they get appropriate care, especially when the alternative is utter destitution and death.
I think that’s an incredibly risky philosophical position to take that should be examined in conjunction with discussing it with people of varying mental illnesses and recovery statuses.
Especially when we discuss the sane choosing for the insane we run the risk of unknown cruelty. Mentally well people have a long history of assuming they know what’s best for the unwell and in doing so accidentally doing something harmful. Things like criticizing the bodies of anorexic people, shaming those struggling with executive function, blunt refutation of delusion, basically whatever Phil McGraw does on his show.
So is it anyone with a mental illness that refuses treatment that can be institutionalized? Only certain disorders/symptoms? Only certain severities? Will we know it when we see it or will we accept that some people who seem like they should be won’t be or vice versa? Are we comfortable with the risks of abuse of power here? What about the weight of bias from the part of the mental health professionals assuming anyone in front of them must be unwell? In diagnosis there is no madman’s advocate, even when the cost of diagnosis is difficult to distinguish from imprisonment.
That’s the whole point, if the insane had the capacity to choose for themselves, they wouldn’t be insane. 😉
I argue that if personal autonomy leads to being homeless on the side of the freeway and, ultimately a miserable existence and death, society has an obligation to step in.
At some point, someone needs to recognize that that level of autonomy is going to cause a preventable death.
I believe society also has an obligation to step in, but with an open hand and possibly some incentives, not with a display of force. And yes, involuntarily institutionalizing someone is a display of force.
And my questions remain: define insanity as it is something you are willing to deny self determination to someone over and decide where the limits are in each direction. And the fact that you didn’t acknowledge the study I linked to the Wikipedia page for says a lot. The Rosenhan Experiment is a large part of why we drastically cut down on forced institutionalizations in the US, because psychiatrists were not getting the consistency in diagnosis to justify what they were doing.
Insanity isn’t a single thing, its a values based severity and pattern judgement of mental behavior that people make. A person with delusions is one of the archetypal “insane” people and yet some of them can hold a job and seem fine until the topic of aliens comes up. A person with executive function disorders may struggle to hold down a job while being fully aware and desiring to do so, but the idea of a padded cell may be so horrifying to them that they’d rather risk dying outside to it (and yet these disorders are quite common in significantly milder forms). Hallucinations are extremely stigmatized, but also in their mildest form they’re just normal (hearing your name in random noises for example). A person who chooses to live in a van traveling and performing for little money even when they have far more successful opportunities may be called insane by some, and I’m strongly suspicious that the ratio is dependent on their performance skills.
That’s before it gets political. To a person in China, Patrick Henry might be declared insane for asserting that if he cannot be given liberty then he should be given death. There are sitting congresspeople who want to institutionalize critics of the president and trans people. If you grant the power to institutionalize people without strict limits and controls you create a weapon of repression.
A person who speaks out against the party in a totalitarian regime may lose their job and home, and in such a case insanity and integrity may become identical. Hell someone in the 1970s insisting that the government is attempting to mind control people by dosing them with LSD and is infiltrating left wing organizations to disrupt them. At the time that was insane conspiracy theorism, today that’s American history thanks to the reveal of MK ULTRA and COINTELPRO. A hundred and fifty years ago you could be institutionalized for shit that horrifies people today.
The fact is, I’m comfortable with risking that some people die if it means everyone has more freedom from excesses in government force. I already accepted it with criminal justice as a part of my opposition to the absurd sentences America has and our fear of recidivism. I don’t want that person you talked about to suffer, I’d much rather that she get help. But when you give the government or medical institutions the power to lock up those they deem irrational and incapable of making their own choices you give them the power to strip freedoms from those they choose.
There’s a lot of writing on this, much of it is from those with a history of mental illness. I highly recommend reading some to better argue against it.
The inherent problem with the Rosenham Experiment is that it involved sane people actively attempting to deceive doctors. That has no bearing on a sane person being incorrectly diagnosed assuming they do not attempt to appear to be insane.
In fact, that entire experiment is more or less discounted as fraud these days:
Mental health professionals, in fact, take the ‘mental’ part out, health professionals in general assume that people presenting a medical condition are honest brokers*, they can’t be faulted for failing to detect unreliable narrators.
* With the notable exception of women and minorities. Doctors seem all too willing to discount self reporting by women and minorities, that’s an entirely separate issue.
But to get back to your larger point of how do you define mental illness severe enough to when society needs to step in and take over:
It should be super simple. When your mental illness reaches a point where it’s having a systemic impact on others.
The lady sleeping on the freeway is actively posing a danger to other people. If some motorist hits her, she’s not the only person who is going to be critically injured. She needs to be removed and treated.
Or, take animal hoarders for example, they are actively posing a danger to the innocent animals they have collected.
It’s the whole “your right to swing your fist ends at the tip of my nose.” Someone quietly going insane, not bothering anyone and refusing treatment is far different than, say, someone wandering into traffic waving a sword around.
When your problem becomes someone elses problem, it becomes all of ours problem. That’s when someone steps in. I’d much rather have it be a psych ward than the cops.
Leaving someone to die at the side of the road is not humanitarian.
Forcing someone to undergo potentially mind-altering medical treatment (because they absolutely will drug someone who fights against being there) and probably abuse (just check the stats) at the hands of the system isn’t humanitarian either.
This is one of those situations where all you can really do is make sure the options are as good as they can be, so people want to choose to get help, and we are not even remotely doing that.
Severely mentally ill people don’t want to choose help, that’s a function of being severely mentally ill. Leaving the decision making to people fundamentally incapable of making a decision actively harms them.
If the system was actually helpful to people, and severely ill patients still didn’t want help, you might have a point. Right now though, the system doesn’t help most people, it harms them actively, so we don’t actually know how many people would still refuse quality care.
And let’s be serious here, the number of people so mentally ill they can’t be trusted to make a decision about whether or not to take offered help…? Really really small percentage. We definitely shouldn’t be structuring the entire system based on edge cases, even if those edge cases have a legitimate need for that sort of inhumane treatment (a premise I strongly question).
That’s an argument to fix the system, which I 110% agree with. That doesn’t mean we shouldn’t get people the help they need.
Yes, however it’s mostly a refutation to your prior comment that severely mentally ill people refuse treatment as a direct consequence of being mentally ill. This is only rarely the case. The vast majority of those severely mentally ill people are still people capable of learning about stuff and doing cost-benefit analysis for their own lives. They make rational decisions to the best of their ability. This ability may be flawed, but that’s the case for all people. Nobody has a pure, 100% complete and accurate view of things.
They refuse treatment largely because the system is horrible. Would they still refuse if the system wasn’t horrible? Most of them probably would not, because struggling is really hard. Most of them would get themselves the help they feel they need if they honestly thought there would be a good outcome.
But what they think they need and what the system or society thinks they need aren’t necessarily the same thing. Maybe all they really -need- is a place to exist exactly as they are, with zero medical intervention, with a clean environment where they feel safe and secure. If that’s all you felt you needed, would you risk being drugged for the rest of your life? I sure as hell wouldn’t, no matter how bad my experience of existence is. At least I have agency.
And honestly until we reach that point, where mental healthcare is supportive to the individual and genuinely helps them live whatever they feel is a fulfilling life, discussing what to do with the minuscule remaining fraction of sufferers (a number we genuinely can’t even quantify at this point) is sort of dumb, and seems like a pretty big distraction from doing anything better for everyone who isn’t in that camp.
They percieve the system as being horrible, but again, that’s a function of their mental illness.
The system does have problems, but there’s no refuting the fact that whatever problems the system has, it’s infinitely better than an amputee with an infected leg sitting in the dirt with no shelter.
I do refute that “fact”, though.
I personally would rather be an amputee on the side of the road with no shelter than be kept prisoner in my own body with the use of drugs and restraints. That’s literally my worst nightmare. And I’m not “severely mentally ill”.
You don’t know what reasons she has for doing what she does, but what IS completely, abundantly, crystal clear, is that she herself considers the position she is presently in to be better than whatever she would potentially deal with under care. And you don’t know why she came to this conclusion. Maybe she was institutionalized when she was young and was abused or whatever and has ptsd about it. Maybe she knows someone else who was.
Or yeah, maybe she’s so mentally ill that it’s forcing her to deny care. I strongly doubt it, but maybe. And we’ll never know unless we fix everything else first. So. Kinda moot point, isn’t it?
Neither is forcing them to accept care they don’t want.
That’s still better than letting an amputee sit in the dirt, feet away from freeway traffic, unprotected in 100° heat.
At some point there needs to be a competency hearing and the person cared for even if they can’t or won’t ask for it. ESPECIALLY if they can’t or won’t ask for it.
The alternative is going “Welp, too bad they died, nothing we could do.”
This is something you and I aren’t going to agree on. From my perspective its an issue of consent. From yours (it seems) and issue of wellbeing. Our heirarchies of needs seem to value personal agency at different levels. I consider it to be a core need, and from that perspective I would never (given the power to do so) exert my will to care for someone as a ward of the state or whatever org I represent without the consent of the individual to be cared for.
I also recognize what you’re saying, that at a certain level of incompetence a person should no longer be able to advocate for themselves and should be required to accept care.
I personally believe that if a person can communicate, they can communicate consent. If a person is completely unable to communicate, it may be a good idea to give them a period of investigative and protective custody to determine their safety, but from their perspective that could be a kidnapping.
I’m not saying your perspective is wrong, but this is a situation that needs to be handled with extreme nuance and care by professionals.
On competency evaluations:
I’d need a large panel of Psyches from the same and similar communit(y/ies) as the JD (john doe/ jane doe) to all agree they are incompetent before I’d be comfortable allowing their consent to be violated in the manner of state endorsed internment in medical or mental facilities. If the medical community agrees, and the people around the JD agree, then and only then should the JD be given care without their consent.
I think the difference in our opinions are less than you think it is, you argue from a point of personal autonomy, and I get that, my argument is they have already lost their autonomy due to mental illness.
So if they have no autonomy already, society needs to error on the side of making sure they get appropriate care, especially when the alternative is utter destitution and death.
I think that’s an incredibly risky philosophical position to take that should be examined in conjunction with discussing it with people of varying mental illnesses and recovery statuses.
Especially when we discuss the sane choosing for the insane we run the risk of unknown cruelty. Mentally well people have a long history of assuming they know what’s best for the unwell and in doing so accidentally doing something harmful. Things like criticizing the bodies of anorexic people, shaming those struggling with executive function, blunt refutation of delusion, basically whatever Phil McGraw does on his show.
So is it anyone with a mental illness that refuses treatment that can be institutionalized? Only certain disorders/symptoms? Only certain severities? Will we know it when we see it or will we accept that some people who seem like they should be won’t be or vice versa? Are we comfortable with the risks of abuse of power here? What about the weight of bias from the part of the mental health professionals assuming anyone in front of them must be unwell? In diagnosis there is no madman’s advocate, even when the cost of diagnosis is difficult to distinguish from imprisonment.
That’s the whole point, if the insane had the capacity to choose for themselves, they wouldn’t be insane. 😉
I argue that if personal autonomy leads to being homeless on the side of the freeway and, ultimately a miserable existence and death, society has an obligation to step in.
At some point, someone needs to recognize that that level of autonomy is going to cause a preventable death.
I believe society also has an obligation to step in, but with an open hand and possibly some incentives, not with a display of force. And yes, involuntarily institutionalizing someone is a display of force.
And my questions remain: define insanity as it is something you are willing to deny self determination to someone over and decide where the limits are in each direction. And the fact that you didn’t acknowledge the study I linked to the Wikipedia page for says a lot. The Rosenhan Experiment is a large part of why we drastically cut down on forced institutionalizations in the US, because psychiatrists were not getting the consistency in diagnosis to justify what they were doing.
Insanity isn’t a single thing, its a values based severity and pattern judgement of mental behavior that people make. A person with delusions is one of the archetypal “insane” people and yet some of them can hold a job and seem fine until the topic of aliens comes up. A person with executive function disorders may struggle to hold down a job while being fully aware and desiring to do so, but the idea of a padded cell may be so horrifying to them that they’d rather risk dying outside to it (and yet these disorders are quite common in significantly milder forms). Hallucinations are extremely stigmatized, but also in their mildest form they’re just normal (hearing your name in random noises for example). A person who chooses to live in a van traveling and performing for little money even when they have far more successful opportunities may be called insane by some, and I’m strongly suspicious that the ratio is dependent on their performance skills.
That’s before it gets political. To a person in China, Patrick Henry might be declared insane for asserting that if he cannot be given liberty then he should be given death. There are sitting congresspeople who want to institutionalize critics of the president and trans people. If you grant the power to institutionalize people without strict limits and controls you create a weapon of repression.
A person who speaks out against the party in a totalitarian regime may lose their job and home, and in such a case insanity and integrity may become identical. Hell someone in the 1970s insisting that the government is attempting to mind control people by dosing them with LSD and is infiltrating left wing organizations to disrupt them. At the time that was insane conspiracy theorism, today that’s American history thanks to the reveal of MK ULTRA and COINTELPRO. A hundred and fifty years ago you could be institutionalized for shit that horrifies people today.
The fact is, I’m comfortable with risking that some people die if it means everyone has more freedom from excesses in government force. I already accepted it with criminal justice as a part of my opposition to the absurd sentences America has and our fear of recidivism. I don’t want that person you talked about to suffer, I’d much rather that she get help. But when you give the government or medical institutions the power to lock up those they deem irrational and incapable of making their own choices you give them the power to strip freedoms from those they choose.
There’s a lot of writing on this, much of it is from those with a history of mental illness. I highly recommend reading some to better argue against it.
The inherent problem with the Rosenham Experiment is that it involved sane people actively attempting to deceive doctors. That has no bearing on a sane person being incorrectly diagnosed assuming they do not attempt to appear to be insane.
In fact, that entire experiment is more or less discounted as fraud these days:
https://www.sciencehistory.org/stories/distillations-pod/the-fraud-that-transformed-psychiatry/
Mental health professionals, in fact, take the ‘mental’ part out, health professionals in general assume that people presenting a medical condition are honest brokers*, they can’t be faulted for failing to detect unreliable narrators.
* With the notable exception of women and minorities. Doctors seem all too willing to discount self reporting by women and minorities, that’s an entirely separate issue.
https://www.health.harvard.edu/pain/the-dangerous-dismissal-of-womens-pain
https://www.hopkinsmedicine.org/news/articles/2021/06/physicians-more-likely-to-doubt-black-patients
But to get back to your larger point of how do you define mental illness severe enough to when society needs to step in and take over:
It should be super simple. When your mental illness reaches a point where it’s having a systemic impact on others.
The lady sleeping on the freeway is actively posing a danger to other people. If some motorist hits her, she’s not the only person who is going to be critically injured. She needs to be removed and treated.
Or, take animal hoarders for example, they are actively posing a danger to the innocent animals they have collected.
It’s the whole “your right to swing your fist ends at the tip of my nose.” Someone quietly going insane, not bothering anyone and refusing treatment is far different than, say, someone wandering into traffic waving a sword around.
Man, I WISH I was kidding about that last one.
https://www.oregonlive.com/portland/2015/05/sword-wielding_bipolar_man_in.html
When your problem becomes someone elses problem, it becomes all of ours problem. That’s when someone steps in. I’d much rather have it be a psych ward than the cops.