Sunday, April 03, 2016
My Brother Ron
Scott Alexander over at Slate Star Codex reviews Clayton Cramer's book My Brother Ron. I have commented in a small email circle of mine, but there is so much going on for me here that I will wait until i have better control over what I would like to say. A great deal of my worklife, my political changes, and how I perceive myself is in this topic. For the moment, I will only say that I agree with virtually all of Alexander's take on this.
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8 comments:
Wow. I heard of the ACLU role, but at the time I was in no position to evaluate the expert opinion. Is "My Brother Ron"s take on the quality of the influential experts of the era accurate?
If you mean "across the eras," yes. If you mean a specific era, I'm not getting which one and there may be more to say.
He wrote of 2 that the review considered instrumental in the deinstitutionalization effort; one of which had avoided experience with psychotic patients during his education.
Szasz and Laing. Required reading by everyone in psychiatry, psychology, social work. Yes, both very big, very influential. Even in their day they were controversial, but they were regarded as authorities. Neither were idiots. Szasz had interesting observations about personality disorders, drug addiction, and the pathologising of normal human problems. Laing was a deeply compassionate man. But their foundational premises led them astray, taking many of us with them.
I found this comment very interesting:
"Hmmm. . . . once upon a time I read of a study that concluded that more structured society was, the more depression and less psychosis you got.
"And then tested it by looking at, IIRC, Mennonites, to find that psychosis was very rare, and depression was so common that they had a name for it — wrestling with an angel — and their low suicide rate was caused by the community support for the depressed."
I can easily believe that among the homeless (a population highly enriched in the mentally ill), having to hang around the disturbed so much would tend to train habits of distrust and even of aggressive attitudes--you have to protect yourself somehow. It could make you look weirder than you are. But would that actually create problems, or balloon minor quirks into major issues? No clue.
I'd been meaning to comment on this for a while but just got around to it (quicker than 9 years). I read Clayton's blog over a time that including extemporaneous accounts of contacts with his brother and research anecdotes, though not the book.
I get a whiff of straw in the focus on reviving institutionalization. My reading of Clayton was his primary frustrations were two-fold. One that it was so difficult to obtain an involuntary commitment for someone who became dangerous when he was non-compliant with his medications, and who was pretty regular in his non-compliance. The second frustration I gathered was that even if commitment had been easier, there was just no place for him to go. I didn't get the feeling that Clayton thought that institutionalization was a general solution for people suffering from mental illness but that, as in many cases, it would be a benefit in specific cases, and throwing the baby out with the bath water was a bad idea.
While Scott Alexander acknowledges that the choices around institutionalization are hard, he still focuses on non-compliance as a rational choice. I wasn't terribly impressed with the word salad he chopped and tossed to justify allowing people to turn down three hots and cot in favor of continuing to enjoy Starbucks wi-fi. This seems fine for somebody who isn't particularly dangerous but less so for the psychotic, and doesn't take into account the intersection between the violent and the non-violent in places where they both take shelter.
Even less impressive was his hand waving around involuntary outpatient care. I agree this is probably the best of all possible worlds, especially for therapists who only have to interact with the psychotic once every three months and can spend the rest of their time working with the worried well. My objections are two fold. He's not very specific about who is going to put the 'involuntary' in this care model but it's likely to become the task of the people who carry badges and guns. While an argument can be made that they have implicitly become ward orderlies in the current system (and prisons have become de facto mental institutions to a similar degree), making that function explicit is going to upset some people, both in law enforcement and among the people who expect laws to be enforced. Secondly he seems pretty sanguine that involuntary drug administration would be unobjectionable to society even though he has presented non-compliance with institutionalization as a rational choice. Could not the same argument be made for non-compliance with treatment?
That's a pretty devastating, and completely fair and convincing, critique of Alexander's piece.
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