Monday, April 11, 2016

Update on "My Brother Ron."

Christopher B’s comments under  My Brother Ron are quite good.  The original essay from Slate Star Codex was long, you may recall, and covered a fair bit of territory.  I had been thinking along different lines, so it was good to get reminded of a few important pieces I had let drop away.
I am going to break this into two or even three posts simply for length. More to follow.

NH has both a Conditional Discharge Law and an Outpatient Commitment Law.  We rarely used the latter until a bizarre Medicaid billing regulation backed us into that corner.  Now we use either. Other states are starting to develop outpatient commitment laws, but these are more limited: they can only be granted if the person has been convicted of a crime, for example – which gets odd when a person is incompetent to stand trial, NGRI, or the prosecutor believes treatment would be a better option and would prefer to drop charges.  Also, sometimes medication is the only treatment that can be required, which represents a failure to think things through. Some medications require lab work for safe administration, or to measure whether the meds are being taken (cheeking meds is an art form); sometimes a simple weekly appointment for fifteen minutes conversation and observation can be enough to reveal mood or cognitive changes; lastly, the comorbidity with substance abuse is very high, so forbidding or limiting their use can be important.

There is a natural split between hospitals and community mental health centers in designing outpatient treatment.  The hospitals are full, and overfull.  We have a 50-person queue in emergency rooms across the state awaiting a bed here. We are absolutely not holding people here because we don’t like the cut of their jib. The criticism directed toward hospitals is not that we are holding people too long but that we are releasing dangerous people far too soon.  When we release them on conditions, we are not at all minded to include conditions which will bring them back to the hospital when they don’t need to be here.  The Conditional Discharge Statute is actually quite clear that we are not allowed to mandate what treatment might be good for them or maximize their chances of having a good life.  We are only allowed to require they comply with treatment that prevents rehospitalisation.

Insurers are even more radical than we are in this.  If a person has not been actively suicidal the last 24 hours they will refuse to certify further hospitalization, regardless of the severity of the attempt or whether the person’s symptoms have improved.

Community Mental Health Centers, on the other hand, see the lives in community that people are actually living and advocate for us to increase the requirements of what treatment a patient should comply with. I get it.  They see bad lives, they see that with just a tweak and a heavy hand they could use the full weight of the state and rescue someone. Tony does better when he has some sort of daily activity to get up for, so we want to mandate a day program, volunteer work, or meeting with voc rehab. Debra’s sobriety is key so we  want her to attend AA 3x/week. Or better (worse) yet, We want to mandate her to a 28-day rehab before she comes back to the community (which involves staying in an acute psychiatric facility until we can get her into one of those, of course). If Jon had to go over to the MHC every morning to get his meds it would get him up and moving. Amber really needs DBT, we want that to be one of the conditions.  Whenever Lucas goes up to visit his mother in Laconia it’s a sign that he’s not doing well; we want to be able to revoke him for that. When Daniel starts talking about the Holy Spirit it means he’s decompensating. Natasha would feel better about herself if she lost weight – can we require some sort of exercise plan and only going grocery shopping with her functional support staff?

These interventions start out based in kindness but get out of control fast. Reading Christopher B’s comment reminded me of that fascist streak which was such an important part of pushing me out of liberalism in the 1980’s. The psychiatrists, psychologists, and social workers at the CMHC’s want to make you do what’s good for you – and very often, you are dangerous without it and you should be made to do it.  The attorneys and social workers at Disability Rights and the ACLU want to make the institutions do what is good for them* - and very often the institutions are dangerous without that and they should be made to do otherwise.  Both do much good in the world – but it goes bad so, so fast.

That’s pretty much my view of all mandated regulation.  You scoop up the low-hanging fruit and most egregious injustices at the first pass, and it is almost always a good thing.  Which encourages people to think that the next batch of regulations is going to create a similar improvement.

*Wait, aren’t they advocating on behalf of patients so they have their rights?  No, they are advocating against institutions. They are not without warmth, concern, and compassion, certainly.  But it’s not their big ticket item.You have to sit across a table - or a courtroom - from them a dozen times before you get how pleasurable it is to them to make big institutions do what they tell them. Sniffing that, sensing that, absorbing that in the 1980's was very powerful for me.


RichardJohnson said...

Reading Christopher B’s comment reminded me of that fascist streak which was such an important part of pushing me out of liberalism in the 1980’s. The psychiatrists, psychologists, and social workers at the CMHC’s want to make you do what’s good for you – and very often, you are dangerous without it and you should be made to do it.

Back in the day I worked a year as an aide, a.k.a. Mental Health Worker, at a psychiatric hospital. I remember that a big part of the patient-staff interaction was to get the patient to accept the staff's interpretation of what was going on. All for the patient's good. Which by and large it was.

Around that time, One Flew Over the Cuckoo's Nest was available in print and in film version. Many viewed Nurse Ratched simply as a fascist who wanted to control everything. I viewed Nurse Ratched as a metaphor for the welfare state: you need to do this for your own good. After all, this is what staff implicitly or explicitly said to the patients.

Sam L. said...

Remember, THEY know what's best for you, and others. They KNOW.

RichardJohnson said...

Remember, THEY know what's best for you, and others. They KNOW.

I concluded from my year working in a psych hospital that sometimes THEY could help, and sometimes THEY couldn't, with all variations between. Many mental health problems are close to intractable, I concluded. While those with mental health problems needed - and need- help- it wasn't always easy to determine what would help and wouldn't help. [Though it appears that cognitive behavioral therapy helps more then Freudian therapy.]

After seeing dedicated professionals deal with psych patients with varying success, I developed a skepticism for those claiming that they had THE social program that would really help things. Just fund it, and good things will result. Guaranteed. I saw from the psych hospital that funding was no guarantee for success.

GraniteDad said...

First pass vs all subsequent passes:

I ran into this wall working Six Sigma projects at work. The first time someone comes in and starts using data to evaluate things, you can save enormous amounts of money and time, I make everyone's life better, with just some serious analysis. The lightbulb comes on for people as you take a step back, and say "Why do we have 15 steps, but only 5 that matter?" It's exhilarating.

Then five more people get their Six Sigma certification, and you have six people looking for projects to do. You reach the point of diminishing returns very quickly, where people are trying to re-do a process that was redone year ago. It's relatively easy with the training you receive to clear the fat out of the system. But then the easy stuff is gone. And people are still looking to do something else.

Texan99 said...

New vice-president syndrome: someone shows up and has to put his stamp on the process.