Wednesday, March 7, 2018

Why Involuntary Commitment?

Anecdotal evidence does not make good science. It does not make good policy, either.

When addressing Norman Ornstein’s account of having his adult son committed to a mental health facility involuntarily we must consider that we are dealing with anecdotal evidence and with grieving parents.

When Ornstein was informed that his adult son was behaving erratically and seemed to be dangerous, he flew to Sarasota, FL where the young man was living. He filled out the forms to have him committed. Apparently, it was a very easy process… which leads us to ask why no one did it for Nikolas Cruz.

Ornstein tells us that his son’s illness began suddenly when the young man was 24. It is a little late for the onset of schizophrenia, but one suspects that Ornstein’s son was suffering from psychosis. The Times column does not provide us with a diagnosis, but we know that the young man was held for seventy two hours and released.

An earlier column, also written by Ornstein, offers more details:

At age 24, Matthew had a sudden psychotic break, and that began a difficult decade-long journey for him and for his family and friends. Whatever his illness — his condition was never formally diagnosed, but he probably suffered from bipolar disorder — Matthew was particularly afflicted by one component of his illness: anosognosia, the inability of a person to recognize that he or she is ill. Since Matthew was over 18, neither family members nor professionals had any legal authority to get him treatment for the symptoms that kept him from living a stable life.

Astonishingly, Matthew was never diagnosed. Whatever do psychiatrists do if they cannot diagnose a case of schizophrenia. He might have suffered from bipolar disorder but sudden psychotic breaks are more often associated with schizophrenia. Dare we say that both conditions are treatable? And that, as Ornstein importantly notices, if the young man did not recognize that he was ill, then shouldn’t the proper authorities be allowed to do what is best for him.

In today’s column, Ornstein describes what happened after he signed the commitment papers. He blames the police and the system for traumatizing his son:

In a panic, we flew to Sarasota, went to the courthouse and filled out the forms to invoke the Baker Act. It was surprisingly easy.

When we got to the condo, Matthew was already gone.

We later learned what had happened next. He had just emerged from the shower when police officers cuffed him — without letting him dress or pick up his cellphone, or even explaining what was happening. He was transported to a county mental health facility.

We followed, desperate to see our son. But the staff members wouldn’t let us in. In fact, they said privacy rules meant that they could not even confirm that he was there.

Worst of all, we found out we had been duped. The condo manager who had called us had concocted the story as a pretext to get our son off the property. Because Matthew had long hair and a beard, smoked and tended to wander on the beach at 3 a.m., the manager thought he might scare away those renting other units — and he just wanted Matthew out.

The Baker Act allows 72 hours of involuntary observation to see whether someone is in fact an imminent danger to himself or others. Matthew was not, and after three awful days, he was put in a taxi and sent home. We were not informed when he was released.

Evidently, three days is not sufficient to offer any treatment. Psychopharmaceutical treatments of psychosis are far from perfect, but they are far more effective than they have ever been. True enough, seventy-two hours is hardly sufficient. Leaving the young man untreated was medically and judicially irresponsible.

Ornstein blames the police and the mental health system for having driven a wedge between him and his son:

Our relationship with our son was deeply damaged by this incident, making any further efforts by us to help him infinitely more difficult. It did nothing to help him deal with his condition and only increased his sense of being stigmatized and hounded. He moved out of Florida and died in an accident at age 34.

Clearly, treatment should have been administered, even if the young man did not want it. And yet, the standard of “imminent danger” did not allow the mental health system to hold him for more than three days. One remarks in passing that if Nikolas Cruz was not an “imminent danger” the term has no meaning.

All things considered, the trauma of being picked up by police was the least of this young man’s problems.

Besides, how much confidence should we have in the psychiatric system and its ability to judge imminent danger? One suspects that simple minded professionals ask patients whether they want to kill themselves or anyone else and mark their word down as definitive.

Ornstein adds that we do not hold patients with psychiatric illnesses for very long because we do not have the beds to do it. He does not mention the advocacy groups that worked to empty out the psychiatric hospitals several decades ago and who defend the rights of psychotics to walk free in our communities. Blaming the NRA or guns is far easier than casting a cold eye on the consequences of the disastrous work of the ACLU in this field.

He sees the consequences of the failed mental health policies, but does not affix responsibility:

We have far too few beds in mental health facilities, so most people who have a serious illness and are picked up for offenses like vagrancy from homelessness or drug possession (many people with mental illness self-medicate with drugs) end up in jails, where they lack treatment and almost invariably deteriorate.

The fault lays with the system, for failing to treat people who are clearly ill and who do not know they are ill. I would have preferred that Ornstein affix some of the responsibility to those who were the authors of the new policy and who have militated for decades to ensure that psychotics not receive treatment.

Refusing to treat a treatable illness in the name of an ideal is cruel.

[See also Walter Williams' column, link here. Via Maggie's Farm)


Ares Olympus said...
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Jack Fisher said...

"Besides, how much confidence should we have in the psychiatric system and its ability to judge imminent danger? One suspects that simple minded professionals ask patients whether they want to kill themselves or anyone else and mark their word down as definitive."

You are extremely misinformed here. Because involuntary holds by nature implicate medical issues and constitutional rights, the procedure is very thorough while protecting the public and the individual. Patients are represented by advocates and are allowed to cross-examine state witnesses.

Here is an outline of how it is done in California:

Here is a description of your "simple minded professionals", taken from a California statute:

"The certification review hearing shall be conducted by either a court-appointed commissioner or a referee, or a certification review hearing officer.  The certification review hearing officer shall be either a state qualified administrative law hearing officer, a physician and surgeon, a licensed psychologist, a registered nurse, a lawyer, a certified law student, a licensed clinical social worker, a licensed marriage and family therapist, or a licensed professional clinical counselor.  Licensed psychologists, licensed clinical social workers, licensed marriage and family therapists, licensed professional clinical counselors, and registered nurses who serve as certification review hearing officers shall have had a minimum of five years' experience in mental health.  Certification review hearing officers shall be selected from a list of eligible persons unanimously approved by a panel composed of the local mental health director, the county public defender, and the county counsel or district attorney designated by the county board of supervisors.  No employee of the county mental health program or of any facility designated by the county and approved by the State Department of Social Services as a facility for 72-hour treatment and evaluation may serve as a certification review hearing officer."

Stuart Schneiderman said...

If the professionals in Florida could not diagnose Matthew Ornstein, I do not really care about all of their credentials or the directives contained in the law. Having the right credentials does not mean that one does a good job. If you do not like calling them simple minded, then we should consider why it is that they do such a bad job. The streets of our cities and our jails are filled with people who have mental illnesses, but who cannot be committed or treated. See also the Walter Williams article. Most of the restrictions simply make it more difficult to treat people who have what psychiatrists recognize today as a brain disease. And they even know that people suffering this illness do not recognize that they are all. I cannot imagine any other civilized countries treating the mentally ill this badly.

Jack Fisher said...

The state cannot detain anyone without due process, that is a consequence of the constitution. If it makes treating people more difficult because there are other fundamental rights in the balance, then that is also a consequence.

The mental health system is a compromise between extended involuntary commitment, a hallmark of the Soviet gulag for decades, and no treatment at all. While it fails at completely satisfying everyone it is the best compromise. The failure in Florida seems to be, frankly, that no one gave enough of a shi'ite about the kid, meaning whoever his caretakers were and the Broward County LEOs who were apparently instructed to overlook school crimes. The system works if and only if people are motivated to make it work. Professionals might have done their job if MO were taken into custody on a psychiatric hold, evaluated, medicated and then made a case for continued involuntarily treatment before a qualified hearing officer.

Having the right credentials -- Florida's Baker Act requires medical professionals. Involuntary commitment requires three opinions, two of whom are psychiatrists or clinical psychologists who personally examined the patient. So before calling them simple-minded you need to either know what their credentials are or or point out something specific rather than make a generic ad hominems. You cannot judge a system by cherry picking a single example.

Baker Act excerpt:

This discussion risks falling into a series of ipse dixit claims, aggravated by the fact that I am not a medical processional and you are not a lawyer.

Stuart Schneiderman said...

It isn't very much of a compromise when it leans strongly toward no treatment at all. I worked for several years in a psychiatric clinic in France several decades ago... and they were far more willing to treat psychotics without having to go through lengthy court procedures and without throwing them out on the street because they did not know how ill they were. And it did not turn into the Gulag. Please....

Ares Olympus said...

Stuart: Refusing to treat a treatable illness in the name of an ideal is cruel.

As best I can tell diagnosing mental illness is something harder than rocket science. Rockets will blow up, but mostly it's just money to build up your learning curve.

I'm not sure what it means for an illness to be "treatable", how that differs from "curable" vs "manageable". Bad thinking (or stinking thinking as another name) is almost a sign of being human, and being capable of being hurt by others, rather than a sign of a unique problem of a broken mind.

I believe in the idea of "intervention" but in practice, I don't know what it should look like, probably closer to what a church community can do when someone is acting self-destructively, like drug abuse, than impersonal public institutions that reduce people to a diagnosis that has to be controlled.

Jack Fisher said...

the problem in Florida wasn't the reluctance to treat, the Baker Act standards don't appear to be high for the initial confinement or for extensions of involuntary treatment. the problem in Florida is that no one invoked them. Had someone done so, Cruz probably would have been held longer than 72 hours.

France recently reformed its medical health laws, and now looks remarkably like Florida's, with a 12 and 72 hour holds and judicial review of the hold at 12 days.


Stories about US insane asylums before "involuntary" was a thing make fascinating reading, e.g., One flew over the cuckoo's nest and The bell jar.

Jack Fisher said...

AO, just for once, spend five minutes reading up on the topic before you blather your opinions.

Ares Olympus said...

Jack Fisher, I read Ornstein express dismay at reality and uselessness of the 72 hour rule, in direct experience with his son. I would like to believe there is a better way, and I'm sure there is, but I not sure anything can be done on the cheap or that forced hospitalizations can successfully be used to reduce mass murder.

Jack Fisher said...

AO, do you have a point to make?

Stuart Schneiderman said...

Conditions in psychiatric institutions depended in very large part on the quality of the medical treatment available and on whether patients could be forced to take their medication. This has changed radically over the years... when they decided to empty out the psychiatric hospitals they promised that the patients could function as outpatients... but only if they took their medicine. Naturally, they did not. Ergo.

The issue of diagnosis concerns the diagnostic skills of the psychiatrist...if they could not diagnose Matthew Ornstein, I believe their skills to be deficient. No psychiatrist I knew in the old days would have missed the diagnosis.

As for French psychiatry, one recalls that, a few years ago, a psychiatrist in Marseille allowed a patient to leave the hospital... when her colleagues thought it unwise. The patient went out and murdered someone and the state prosecuted the psychiatrist for manslaughter.