Monday, January 17, 2011

Revisiting The Cost

As the mental health debate - by which I mean the "why are we letting obviously crazy people run loose so they can shoot people in Tucson" hand-wringing comments, with no credible solutions offered - heats up, I direct readers to my recent post The Cost.

Here's the bottom line of the discussion: If I had met and interviewed Jared Loughner the day before the shooting, he would not have made the top hundred, maybe not the top thousand, of most-dangerous-sounding-people I have met. So all these calls for "better" mental health services for all these troubled people running around leads immediately to the two central questions, How many of those people - those false positives who are walking the streets of NH and haven't hurt anyone - do you want locked up or forcibly treated, even though they haven't done anything dangerous, just sounded dangerous? And Are you willing to pay for that? The upper number for the first question could run to a million people. The cost would be at least ten times, and more likely a hundred times more than we are paying now.

That's the reality. People blathering about the issue who don't recognise the scope of the problem, how many people we are talking about and how different the rights of a society are when you do that, really shouldn't be talking.

We have chosen our level of safety. It's not an accident, it's a reflection of a hundred cultural values.


Retriever said...

Well said. Even tho, as a relative of people who have (in the past) been dangerous and completely out of control, the current system has at times frustrated me. It's still better to live in a free society that respects people's rights. And nobody could afford to lock up every potentially violent person (even it wouldn't just devolve into a way of going after political enemies).

What isn't said in all the handwringing over the Tucson tragedy is that hundreds, perhaps thousands of family members of disturbed people are injured and killed every year without much notice being taken, because the system does not allow for preemptively locking people up.

We've been told with a straight face in the past by clinicians "I can't do anything. Just because you are afraid that X will hurt you means nothing. If they assault you, call the police." A young relative kept begging the hospital to admit someone in the family, was told they couldn't because person objected, only when they physically assaulted her could it happen.

karrde said...

A historian and blogger named Clayton Cramer has dome some research into the transition from easy-involuntary-committal to hard-involuntary-committal for mentally ill patients. (Teaser for the book that has so far not found a willing publisher, plus a couple of posts.)

He is of the opinion that the tales of mostly-sane people held against their will are more myth than fact. I don't know enough to either agree or disagree with him.

I do know that the difference between mentally-different and mentally-ill can be pretty fuzzy. I just don't know of a good way to deal with that problem.

HayZeus said...

Cramer's work is interesting (and if he's able to publish his book I'll probably read it) but I'm not sure if I agree with Clayton's premise either, especially when one can still find allegations of improper committal. There may well be other sides to this story that are not apparent in the article but I know when I read it I found myself wondering just how different from my state the laws in New York must be given that they seem to allow a TDO based on the possibility of paranoia. My state views most of these situations as law enforcement issues and not mental health issues and our MH providers can only actively intervene when an individual is an imminent physical threat to themselves or others.

Assistant Village Idiot said...

HayZeus, I saw that link at Insty and wrote back, but it didn't make the cut for an update.

Coupla things. Neither the school nor the hospital can tell their side of it, because of confidentiality. I confess a bias because I have been on the other side of this so often. Most of my patients believe it was completely unreasonable that they were brought to our hospital. The actually unreasonable admissions are seldom the ones brought as unknowns to the ER, but those who are in the MH system and have frustrated the hell out of their providers, who leap at weak excuses to bring them in and smarten them up. But these are, note, people with chronic illnesses whose hospitalization is an overreaction, not made up out of whole cloth.

Paranoid people often do have parts of their story that are true. They cling to that. But I'm guessing that Kings County, like most involuntary hospitals, is overcrowded and not interested in keeping nondangerous people - because they have dangerous ones waiting to come in. So the fact that she was kept two weeks is a red flag to me. It makes her abuse sound worse, but her story would be more convincing if she had only been kept a day or two. Also, most states have probable cause hearings very soon after admission where those sending the patient have to give evidence to a judge that the patient is not only mentally ill, but actively dangerous. The "psychologist only asked a few questions" accusation is also suspicious for that reason. Why a landlord would be filming is also intriguing. There are certainly people who would do that for sexual reasons, but there's no hint of that. So I will hazard an admittedly wild guess that she was doing things that made him suspicious, he wanted to prove it so he could evict her, and stupidly or maliciously broke the law to get evidence.

I don't know any more than you do about the case, but my suspicions are up.

terri said...

I just happened across this Fred Friendly seminar, Minds on the Edge while flipping channels recently and it made me think of this post. Lost of good points....but, of course, no clear solutions.

Still..the perspectives from the panelists, some of whom have mental illness and one in particular who is a practicing psychiatrist who struggles with mental illness was very thought-provoking.

Very relevant, not only to the whole Giffords tragedy, but also relevant to my particular county in which we are having a huge issue with pan-handling and panhandlers with mental illness.

terri said...

A direct link to watch it...Minds on the Edge

Assistant Village Idiot said...

Warm weather equals increased homelessness.

BTW, doing community mental health seems harder to me than what I do.

Retriever, there is also a good deal of variety among states as to how seriously they take suicidality. I find NH one of the most protective states (or restrictive, from another POV) in this regard. Other localities hospitalise a smaller percentage of people presenting at ER's with suicidal thoughts or even plans.

Self-harm, long considered a version of suicidality rather than a separate set of issues, is another matter altogether.