What to do with mentally ill homeless people who refuse help?

http://www.latimes.com/local/california/la-me-lopez-gravely-disabled-0328-story.html

by JumpCrisscross • 9 years ago

56 117 9 years ago

latimes.com

dilap2• 9 years ago

“treatment is a right,” and that “to withhold treatment is cruel.”

That's quite the Orwellian double-speak for incarcerating & drugging people against their will.

humanrebar7• 9 years ago

Well, that enters into an existential question of what "will" is, at least when someone suffers from extreme forms of mental illness.

EDIT: Also, I haven't read the original pamphlet, but not treating chronic mental illness is often cruel to the other members of the community even if it's not cruel to the individual in question.

grovegames• 9 years ago

Regarding your edit; how so?

kome• 9 years ago

Involuntary psychiatric treatment is so problematic that is better not invoke it.

Nomentatus8• 9 years ago

I'm tempted by this answer, too - but the death rates amongst those who are mentally ill but untreated can be pretty spectacular.

alphabettsy2• 9 years ago

Very much so, people have the right to refuse treatment though I do understand they may be thought mentally incapacitated and unable to decide. I kinda lean towards, if they're competent enough to keep themselves alive on the street then they should be able to refuse treatment.

humanrebar7• 9 years ago

I have mixed feelings about this, even. They don't always "keep themselves alive" in a way that healthy to both them and the rest of their communities.

Datenstrom• 9 years ago

I agree but I have a close family member who has been struggling with something similar her whole life. Luckily between disability and family she has never been homeless but for about three decades she was only part time living in reality. It would take getting arrested for making a scene somewhere and court ordered back on medication for her to come back. Luckily she has been doing awesome for long time now, even holding a volunteer job, not sure what the change was. If she was never court ordered I don't think she would have ever came back.

Then again I'm not sure who can be trusted to decide if someone is making decisions based on reality or fantasy.

throwaway7767• 9 years ago

As a counter-anecdote, I know a mentally ill person (mostly functional, luckily, but he gets paranoid delusions during the worst times). His family pressed the doctors hard to have him involuntarily committed one time since he refused to go. From what I can tell, the primary effect of that is that he now has an intense distrust of doctors and those family members, and it would be a lot harder for doctors to help him now, even if they tried to approach him with more empathy.

The only people now who can sometimes talk him down when he's having problems are me and a couple of other family members that did not participate in pushing for involuntary committal.

mercer3• 9 years ago

What I struggle with personally is the question whether it is for us to decide what constitutes 'better off'. Perhaps for some homeless people the best life they can have, at least within our current, flawed system, is on the streets.

Part of the reason why I'm struggling with this question is that since about a year it also applies to me, to an extent. My problem is unrelated to homelessness, but it seems clearer and clearer that the solution that works for me (read: makes me happier and more 'functional' than anything else I've tried) could be considered by many people to be 'worse off', and consequently eligible for some degree of intervention, simply because they are not like myself.

There are no easy answers to these questions, but I feel such answers start with compassion and active engagement with and understanding of those whose lives we are 'managing'. Social workers probably qualify, and the managerial class are probably the last to do so.

csydas• 9 years ago

Well, there is truth to this, but I'm not sure the same set of rules apply to some of the mentally distrubed people being discussed. You can find videos fairly easily of the outlier cases on Youtube, persons who patrol boardwalks and due to whatever malady decide to do things like attack people physically, defecate on people or people's property, break property, and worse. I'm not really sure that they are exercising their free will when their brains have them wired to think there's a demon in a TV display for the bus schedule.

Mental illnesses are heart breaking and they're a problem that most people don't want to deal with; those with extreme cases often are shunned by society and end up in precarious situations and fall further into the illness, making treatment even more difficult. It's a very bad situation that doesn't have a clean answer. While I understand that there is a very large air of caution around setting a precedent that the Government can just declare someone insane and remove their free will, there also has to be a practical side when said person is very clearly a danger to those around them. The penal system wants nothing to do with such cases, current mental health and homeless support doesn't have enough support or funding to help out enough of the cases.

It's just a really shitty situation to be in.

presidentender• 9 years ago

To say nothing of the "right" to demand action by others.

Nomentatus8• 9 years ago

It can be Orwellian, institutions are often self-serving and unreflective. But it isn't always.

I know of a public housing complex that took large numbers of homeless people and had a death rate far over 10% per year despite the fact that every resident had a place to be and an income. If you know people aren't mentally well and are climbing tall bridges by themselves, do you wait 'till they fall off and die? In one case from that building, it turned out the answer (from the government) was "yes."

Part of the problem may well be that high death rates are their own reward, for governments.

meri_dian• 9 years ago

"Celina Alvarez, executive director of the nonprofit Housing Works, said the group needs to make clear that it has no intention of abusing the rights of those with a mental illness or rewriting the law governing involuntary treatment"

Those with a mental illness are in this case unable to help themselves. It controls them. It's the illness that prevents them from getting help. They may refuse medical care but that's the illness talking.

By not committing them to 'involuntary' hospitalization the state is allowing mental illness to slowly kill the suffering homeless population out on the street.

colechristensen• 9 years ago

This is a difficult avenue to walk because it's not very hard to define everyone not doing what you think is right as mentally ill and no longer deserving rights or choice. (see about half of dystopic science fiction)

JumpCrisscross• 9 years ago

see about half of dystopic science fiction

See Alan Turing.

humanrebar7• 9 years ago

This is a difficult avenue to walk because it's not very hard to define everyone not doing what you think is right as mentally ill and no longer deserving rights or choice.

Well, we can start somewhere, right? Like fraudulent panhandling. Or the various forms of low-grade assault that is typically ignored rather than added to a history documenting mental illness.

I have a neighbor who lives on her own that regularly forgets her husband is dead. She leaves the gas stove on. Is it that hard to hold the authorities accountable in documenting that history and certifying that (very sweet when healthy) lady as no longer qualified to live on her own?

tjalfi• 9 years ago

The O'Connor vs. Davidson decision (https://en.wikipedia.org/wiki/O%27Connor_v._Donaldson) is another example.

dilap2• 9 years ago

I think you put entirely too much faith in our ability to diagnose mental illness and entirely too little in respecting the wishes of the individuals themselves.

To be able to say, "I diagnose you as sick, what you want is now invalid" is an incredibly powerful tool, and obviously open for abuse.

Just a few decades ago homosexuality was considered a mental illness. Your line of reasoning would justify involuntary "treatments" for homosexuality. (And in fact, this sometimes happened.)

Today, many of the homeless are likely suffering from schizophrenia. Drug-based treatments for schizophrenia have permanent, non-reversible side-effects, and lower the chance of recovery to basically zero.

Today, as a non-schizophrenic person, I can tell you that if I did develop schizophrenia, I would not wish to be treated with those drugs. Would that wish suddenly become invalid because I was suffering from mental illness?

To my mind, it's pretty evil to force someone to take a drug with permanent side-effects against their will.

unethical_ban• 9 years ago

I agree with the parent and with you. And that's the rub.

If diagnosis were more accurate and peer-reviewed, with paths to release for all people, it may be more tolerable. But if someone can say "You're sick" and take you in, it's too dangerous.

tiku• 9 years ago

Here in the Netherlands we let them live amongst normal people, we then wait untill they stab someone or set their house on fire, because then it is clear they are a danger for society. Oh, and because of cutbacks the government demands that these people pay some cash for their own pills, but these people often don't have a lot of money, so the problem solves itself. Just don't live next to them.

galdosdi2• 9 years ago

Here in the USA, what we do is much dumber than that.

humanrebar7• 9 years ago

"Just don't live next to them" sums it up rather well, actually.

throwasehasdwi3• 9 years ago

The best solution to a homeless problem is to move them somewhere else and make your location less attractive. You can't cure the homeless and crazy and trying to a waste of money. Either put them back in mental wards or accept that they're going to live on the streets and put them somewhere they won't bother anyone.

I have a relative that's homeless and mentally ill and there's absolutely nothing you can do to keep them off the streets. Even with a free place to live he gets kicked out for threatening neighbors or screaming gibberish. Has a criminal record of doing crazy stuff so shelters will give him food but will not let him stay there.

I think anyone that's spent a lot of their life trying to help someone with severe mental illness realizes that the only humane way to deal with these people is to put them in a ward or prison. It's honestly much safer for them there, they get reliable food and some medical care. These types of people are a danger to themselves and being in a controlled environment is the best you can hope for.

I'm personally pleased whenever I hear that my relative is back in jail because then I don't have to worry that he's dying on the side of the road.

Since all the bleeding hearts that haven't dealt with someone in this state keep voting to close down mental wards these people are now flooding the streets, terrorizing people, and dying constantly.

If people don't want mental wards, which is by far the best solution, the alternative becomes putting them on some kind of "homeless island" where they can hurt themselves and each-other but at least not the rest of society.

jdbernard5• 9 years ago

To all of the those who have down-voted this comment, please engage in dialog and don't just down-vote. throwasehasdwi is speaking from personal experience, directly to the question being discussed. If you do not like either of his solutions, what would you advocate instead? Is the status quo of persistent homeless acceptable in your eyes?

hprotagonist2• 9 years ago

This is one of those situations where broad-strokes rules just don't help very much.

"There ought to be a new standard of care, said Ruffin, and it should include not just temporary involuntary psychiatric and physical treatment, but long-term case management."

This is the crux of it. Admitting people to a psych ward for an involuntary hold is ripe for abuse. You can respect someone's autonomy (even a homeless person with psychiatric problems' autonomy) and, at the same time, help them not freeze to death.

It usually starts with having enough caseworkers with enough bureaucratic leeway to build actual relationships with their clients. I don't think we're anywhere close to that.

alexpatin• 9 years ago

This exactly. One needs to establish trust with these people, as they have almost always dealt with some form of trauma one way or another - either physically, emotionally, psychologically, etc.

When this stuff is made into a process, it becomes robotic and the empathetic, human element of it is taken away from it.

These people need someone to listen and understand, not necessarily someone to shove anti-psychotics and whatever else caretakers are told to do.

I'm not saying drugs don't help, but it's best when trust is established, and one can help the patient see why the drug is necessary at the time.

That has always been my problem when seeking help for my psychological issues. I'll see a GP or a specialist, get a prescription, they may go over the mechanism of action with me if I push them to, but otherwise I'm told to take 2 every day and report back in a month.

I'm a lab rat. Not a patient. See why these people have trouble getting help? They don't feel like patients getting treatment.

aglavine• 9 years ago

A lot of people suffer of some kind of mental illness, and it is impossible to establish any kind of trust with them. The problem is to make a process to give the adecuate diagnosys to each person and the right treatment with proper funding and competent personnal. Hard, but not impossible.

humanrebar7• 9 years ago

You can respect someone's autonomy... and, at the same time, help them not freeze to death.

How do you do this at scale? One of the challenges with poverty and mental illness is that it gets hard to provide comfort, safety, and opportunity when the homeless are afraid and distrustful of each other, and often justifiably so.

The reason there are so many niche shelters (women with kids, youth, LGBTQ, etc.) is that there's some consensus that the general population shelters are not safe. Some of that is just vanilla crime, but a lot of it is a result of a high concentration of the homeless who are mentally ill.

And it's not generally a mystery which people are refusing help, medical treatment, or mentorship. At what point does it stop being "respecting autonomy" and start being "enabling dysfunction and abuse"?

hprotagonist2• 9 years ago

You start small, and earn trust with the unhoused in your city over a long time of being a reliable presence. Then you teach other people to do the same, and they start small...

Despite the fact that homelessness writ large is a Societal Issue, social work succeeds or fails two people at a time, and over the course of months and years.

mabbo2• 9 years ago

You can respect someone's autonomy (even a homeless person with psychiatric problems' autonomy) and, at the same time, help them not freeze to death.

Can you? Look, the crux of mental illness is that the organ you use to understand the world and comprehend situations and consequences is broken. If I'm mentally ill, you can't convince me that I'm wrong or that I'm ill anymore than someone with liver disease can process alcohol. That organ doesn't do the job correctly anymore. Logic doesn't apply anymore.

How can you respect my autonomy if I'm wrong about my own safety? If I say "I don't believe the cold can harm me, because I believe there is a fire inside me", your choices are to respect my autonomy and find me dead tomorrow morning after the blizzard, or to not respect my autonomy and I'll be alive tomorrow. Bring an army of caseworkers to tell me I'm wrong- it won't matter. They can all watch me die too.

Edit: to be clear, I'm talking about the most extreme forms of mental illness, the absolute limit. Like a good unit test, always check the extreme examples to see if your solution works.

dangerlibrary• 9 years ago

You are describing an extreme form of mental illness that is not as common as more treatable / manageable forms. If all "mentally ill" people were as incapable of cognition as you suggest, psychology and psychiatry would be very sad, hopeless professions.

theWatcher37• 9 years ago

That, and it's also extremely difficult to diagnose.

We can do blood test for your liver, or scan you for cancer.

The ability to accurately detect/understand/treat mental illness is still in the 1800's relatively...

k-mcgrady• 9 years ago

Mental illness is a very broad spectrum. You can't group it all together and generalise based on that in the same way that you can't generalise all physical illness when it can range from bruising your elbow to breaking every bone in your body.

narag• 9 years ago

Actually I'd say that people being wrong about their own safety and well being is the rule, not the exception.

sgift• 9 years ago

Can you? Look, the crux of mental illness is that the organ you use to understand the world and comprehend situations and consequences is broken. If I'm mentally ill, you can't convince me that I'm wrong or that I'm ill anymore than someone with liver disease can process alcohol. That organ doesn't do the job correctly anymore. Logic doesn't apply anymore.

There are many different mental illnesses and certainly not every one of them in every situation makes your brain unable to do its job anymore. Also, many theories around mental illnesses are actually very vague (e.g. for depression: https://en.wikipedia.org/wiki/Depressive_realism) or the problem that it is very hard to get a conclusive diagnosis which mental illness someone actually has. It happens time and time again that different experts will diagnose different mental illnesses for the same person, because there's no simple test which you can administer, so it is mostly subjective and experience based. Not a good base for "hey, let's decide what's best for these people, because they clearly cannot do it for themselves."

surfmike2• 9 years ago

In CA if someone is an immediate harm to themselves they can still be involuntarily held. Not sure the exact standard that must be met but Wikipedia says they must be "a danger to themselves, a danger to others, and/or gravely disabled." (https://en.m.wikipedia.org/wiki/5150_(involuntary_psychiatri...

The problem is preventing people from getting into that situation in the first place, usually because they are not adequately treating their condition with medications. Better long term care and follow up would help a lot with that.

sixstringtheory• 9 years ago

How can you respect my autonomy if I'm wrong about my own safety?

Curious what your thoughts are on both assisted and unassisted suicide.

wu-ikkyu4• 9 years ago

Look, the crux of mental illness is that the organ you use to understand the world and comprehend situations and consequences is broken.

This popular hypothesis is purely theoretical at best, mythological at worst (except in actual biological illnesses like Alzheimer's). For something to be diagnosed as broken, it must be objectively observable.

If someone is acting weird, the burden of proof that their brain is "broken" is on you to objectively prove. Simply saying "I think their brain is broken because they're not acting like a "normal" person" is subjective unscientific conjecture, no matter how many formalities you dress it up with.

How can you respect my autonomy if I'm wrong about my own safety?

Because if you don't there's no end to this circular logic. Eating McDonald's is bad for your safety. Should we lock up everyone with a pre-disposition to obesity and heart disease so that the tax payers don't have to cover their medical bills while they eat themselves to death? It would be for their own safety after all, right? At least there would be real, tangible, biological evidence for this hypothetical medical tyranny.

bradleyjg• 9 years ago

It's dangerous to try to solve a problem completely in isolation. If a polity puts together a really generous program for street homeless that involves a ton of resources and benefits but has a relative stingy programs for poor people that are living in shelters or doubled up -- what are the possible unintended consequences of that?

rbcgerard• 9 years ago

It's always hard to judge the way people will certainly abuse a new authority over their fellow man

notliketherest• 9 years ago

For the truly mentally ill, reopen the institutions, where they will be safe from harming themselves and others. This will drive down costs tremendously on these cities that suffer from chronic homelessness. Have we got away from that whole 1960s, "One Flew Over the Cookoos Nest" notion that mental institutions are nothing more than jails and that these people are just following their own "movies" and just need to be "let free"? These are sick people that need shelter and help and cannot do it themselves.

pyre• 9 years ago

While many of these people need help, the institutions were closed because they were rife with abuse. It's a playground for predators. If their victims attempt to speak up, you have the choice between believing the "sane" person or the person that is so mentally disabled that they need to be in an institution.

These are sick people that need shelter and help

There is a large amount of literature on how said institutions didn't provide much help other than sedating people and subjecting them to procedures like lobotomy for diagnosis such as "mild" as depression.

19eightyfour10• 9 years ago

To be honest, when I have a lot of money, I want to build housing for homeless people, but there's a difference. They work for us. There's a product that any human can do. We have a couple of floors full of cubicles with terminals. And in exchange for doing X hours of work for Y days per week using this product, a person gets their own room, 3 meals a day at the canteen, and some kind of monetary / card / bitcoin allowance they can use in the outside world. The housing has its own in house security, with monitoring and accountability. Also we vet and include some sort of community building, personality building, NGO / social welfare programs to work with people. It's sort of like an 18th century work house. Without the shame, coercion or slavery aspects.

A very important point is we do not start from the perspective that "these people are 'wrong' and need to be 'fixed'" instead we start from the lovely awesome assumption that these people are humans and are inherently useful. So we get them to do useful things and give them stuff that most people want.

Obviously, some people don't want to be part of any community, and some people would still prefer to live on the street even if they have housing. Such people can work there, but the whole package is really a niche for people who are looking for the whole package.

Basically: food, shelter, work, money, without any hassle at all.

bitJericho2• 9 years ago

If they could work they would.

19eightyfour10• 9 years ago

Maybe the problem is not them. It's the round holes we're trying to fit them into. Maybe if we expand the places they can fit...there can be something they can do.

hashkb• 9 years ago

You have good intentions but need to learn more about how one finds themselves in chronic homelessness first.

If you are expecting something in return, or holding over someone (who may be delusional) a condition for help, you will not end up helping the people you set out to.

19eightyfour10• 9 years ago

I think it's fair to expect something in return. As long as the terms are such that suit the people, they'll be part of it. These people survive on their wits and customs of the street. They're not as hopeless as perhaps is made out. My idea is to redirect their energy and resourcefulness towards something useful, and add some socialization and boundaries that help them interface more fruitfully with normal civilization. But importantly, as a first step, doing useful work in exchange for things they need.

olalonde• 9 years ago

They work for us. There's a product that any human can do.

What are you referring to? What kind of work would they do specifically?

19eightyfour10• 9 years ago

Some kind of work that requires human intelligence that machines are not so great at. No need to say anything more specific yet.

sigstoat2• 9 years ago

To be honest, when I have a lot of money, I want to build housing for homeless people...

based on that plan, i expect you'll spend most of your money on lawyers, dealing with all of the legal / zoning / HR / irs red tape involved in employing people on that sort of basis, while tying it to their housing, which sounds like the sort of thing that's been banned in most cities for decades.

19eightyfour10• 9 years ago

The legal side of it is very important but I don't think it's some fixed position that can't ever change. It's something to engage with and work with. If it was easy...it probably would have been done.

It's not tied to their work specifically, but it is some sort of arrangement where it is to some extent conditional upon their needs, wants and behaviour. It's a multifaceted suitability assessment, where the people we would help still maintain autonomy over what they get -- not like they are just applying to some large bureaucracy hoping to win a lottery.

Spooky23• 9 years ago

My dad worked in public housing in NYC in the 90s when the city prioritized housing the homeless over all others.

It was a disaster -- they brought a scourge of drugs, petty crime and serious issues like sexual predators and outlandish behavior that terrified the other residents.

These people need support, many are in the situation they were in because they lack a support network. That means investing in trained people and keeping them engaged for a long time.

19eightyfour10• 9 years ago

That's the idea. Not just pen them in and let them run amok. But create a controlled community that works to bring out the best in them. I don't really believe anything cannot be overcome.

19eightyfour10• 9 years ago

From the 4 downvotes ( which hurt a bit I'll admit, it's like punishment -- for what? Offering an idea? My instinctive response is 'whatever' to people who want to try to punish people for making ideas. Because this is a problem that needs ideas, punishing discussion is a ridiculous response. The comments I've gotten have not been the exemplar of constructive responses that such ideas and such a topic merit. ) -- I'm sensing there's a lot of negativity to this approach. Along the lines of "how dare you think you can help them." which is not a workable response at all.

From my point of view, I don't really see the need to get so emotional about this. Just see it from a level headed perspective and take some concrete steps. Thinking that such a sad situation can be improved is not something to get so angry about.

But to some extent I understand that...since it is an emotional issue, because it's such a painful one. I think it works to bring some calmness to the approach for excellent results.

Even if I try this and fail the people are not going to be worse off. So why has this proposal garnered your hatred? It really doesn't make you look bad that I have an idea about this and am bold enough to say it, and you don't have any ideas to speak of. So if it doesn't make you look bad, and it's not going to cause any harm, but might actually cause some good, why do you hate it? No need to be afraid of it. What this will be, if it is anything, will be like nothing that has come before.

So your reaction isn't about this idea. Your reaction to this idea is about you. While we could spend some more time discovering what about you it is, I don't want to spend that time so. You should discover what about this idea raises your ire so. That will be a really interesting discovery for you I think. That's what your reaction is about. You should work out why you feel like that.

And while you're doing that, the people who choose to want to contribute to making improvements in this problem and others can get on and do that.

Nomentatus8• 9 years ago

This works for some, no question, and has worked in my area in fact. But it's expensive, and that farm has now closed to save the government some money, more's the pity.

Of course, this can quickly devolve into a workhouse or poorhouse; there's a black history there already. But I understand that that's not what's being proposed.

19eightyfour10• 9 years ago

Thanks for the example of where similar ideas have worked.

joshuaheard• 9 years ago

They need to change the legal standard for involuntary commitment to a psych ward. At present, the standard is that as long as the patient is not a danger to others, they are allowed to roam the streets at will. I think a better standard is to broaden it to where if they can't take care of themselves, they can be involuntarily committed. That used to be called "vagrancy" and was a crime. I would find some middle road where it is not a crime, but a civil order.

accountface• 9 years ago

the patient is not a danger to others

or themselves

I would find some middle road where it is not a crime, but a civil order.

In the past this road has lead to people being committed because someone just didn't like them. Broadening committal to people deemed not acceptable by society is a dangerous path.

nickpinkston• 9 years ago

If they're not a danger to others why not allow them to do what they want? So you can be more comfortable?

jdbernard5• 9 years ago

In my experience it's very hard to prove to the standard required for the authorities to intervene. Basically you have to wait until they have already hurt someone before action can be taken. And it's even worse if they are only a danger to themselves. Worse still if they are simply incapable of sustaining themselves rather than actively suicidal.

Believe it or not many of these people have relatives and friends who do care about them, deeply, but are powerless to help them because in their delusions they have violently rejected their help. I've watched a friend of mine starve nearly to point of death on the street and be unable to do anything to help him other than take him to lunch whenever I could.

cat199• 9 years ago

if they can't take care of themselves

By this definition, everyone on welfare can be incarcerated in a mental institution at any time without cause..

Not mentally ill? Well, perhaps you are, we'll take you in for another screening.

1_2__3• 9 years ago

This has always stuck with me. When I was a lot younger, in the early 90s I was dating a guy who was pretty high up in Washington state's DSHS. I remember him saying that massive cutbacks were forcing all the institutions they had left to close. I asked him naively what the plan was for everyone who was going to be released and he said "Nothing. There is no plan. There're just going to live on the streets."

I was aghast and assumed he had to be wrong somehow. Fast forward ten years and downtown Seattle is full of homeless people. Fast forward to today and multiple cities are basically overrun with them, when the population of them was tiny just 20 years ago.

I hate feeling old and partisan but my personal experience leads me to believe this is the crazy GOP policies of the 80s coming home to roost. It's certainly the most likely explanation given what I know and doesn't require some of the mental backflips necessary for other explanations.

Nomentatus8• 9 years ago

I remember around then being a policy analyst for the Mental Health department of a government and being told (from above) that lots of money would be made available for services in the community once institutions were closed - but knowing perfectly well that it was a bald-faced lie at the time, given which political party was in charge, and their record. As one example, the Social Services manual at the time made it a firing offence to reveal to a client the existence of an available service or entitlement that the client didn't already know about. In print. Or to publish any part of the (quite official) manual.

Kattywumpus• 9 years ago

You mean, "What should the state do?" That's a different question than what ordinary human beings should do.

The notion that someone who said, "Jesus wants me to live on the street," would suddenly find themselves incarcerated and drugged to change their mind is such a terrifying overreach of state power that it boggles the mind.

jdbernard5• 9 years ago

First, I agree with you. Making a policy of judging (often poorly) the state of mind of other people and then forcibly stripping them of their rights based on that decision is a dark road.

But, what do we do when that person changes from "Jesus wants me to live on the street" to "Jesus told me to purify people wearing blue?" Or maybe a less extreme version, "I have been commanded to anoint your car by defecating on it." What is our responsibility as a society to those who through no fault of their own become delusional and dysfunctional to the point where they become abusive towards others? What agent should be charged with this responsibility if not the government?

I don't have a good solution myself. I've just seen the damage mental illness can cause, and it usually isn't limited to the person who is ill. I've had the difficult conversation: "I know they're stalking you, and I know they have a CHL, and I know they are no longer in their right mind, but there are no authorities that can actually do anything until after they directly threaten you in a way that you can prove."

known• 9 years ago

Call 911

vondur• 9 years ago

I'm noticing here in California, many of the mentally ill homeless simply ended up in jail, where they are given some level of care. However, with the recent mandated Federal court order to reduce the prison population, there has been a flood of them back on the streets. I'm also going to speculate that many of the mentally ill also have drug dependency issues.

bannisterp• 9 years ago

I live right in the middle of a hotspot for "street people" in SF. I struggle internally with this question daily, because I see many mentally ill people roaming the streets just outside my apartment. I've run the whole gamut of solutions and emotions for the past 5 years, and I can only come to this solution: let them refuse treatment, but make living on the street the least viable option for them.

I know deep down there isn't much that can be done without incarcerating them, but I also know that taking someone's freedom without proper cause is worse than letting them possibly die by their own choice. There's too much potential to abuse power that let's you lock up someone who is, by and large, law-abiding but mentally disturbed. The hair splitting is dangerous.

That being said, in short order I will likely move to a location in SF where I don't have to see this tragedy play out day to day. If I can't help, and I don't like the current solution, at least I can avoid the situation altogether.

lisper4• 9 years ago

About ten years ago I spent two years on the streets of Santa Monica, California making a documentary film about the homeless people there. This is a clip of an encounter I have with a schizophrenic person on the first day of filming:

http://graceofgodmovie.blogspot.com/2012/01/i-am-super-danny...

It's worth watching all the way through because Daniel undergoes a remarkable transformation over the course of four minutes, simply because I stopped being afraid of him and started treating him with basic respect and decency. It's one of the most important lessons I have ever learned.

Over the course of the next two years I learned a lot more about mental illness and the often subtle ways it can manifest itself, a lot of which is reflected in the film (which you can get on iTunes and Amazon, links are on the home page: http://graceofgodmovie.com/)

It's a very complicated problem. But involuntary commitment to mental institutions is absolutely not the right answer IMHO.

ZeroGravitas3• 9 years ago

FYI the video didn't play for me on Firefox or Chrome on Mac OS X 10.11. Firefox said "Video can't be played as the file is corrupt", note I don't have Flash installed on that browser. On chrome I could hear the audio, and start stop via the controls but not see anything, but it did let me download and view the file.

lisper4• 9 years ago

The video is an MP4. Here's the raw link:

http://graceofgodmovie.com/superdanny.mp4

I could have sworn I put a copy on YouTube but now I can't find it. I'll try uploading it again.

UPDATE: Try this: https://youtu.be/Ah_UglfATU0

wu-ikkyu4• 9 years ago

How is involuntary commitment legal under the constitution?

Mental "patients" (prisoners) are deprived of due process, trial by jury, and are subject to cruel and unusual punishment (forced drugging, solitary confinement) and indefinite imprisonment. This in itself is psychologically damaging and further exacerbates the issue.

If a person hurts someone, they should stand trial but until then they should be allowed their inalienable rights.

maxerickson• 9 years ago

You are defining due process differently than the Supreme Court.

rtkwe2• 9 years ago

The constitution doesn't guarantee/require a trial by jury outside of criminal cases. Since involuntary commitment is not a criminal case it only requires due process which is simply a normalized legal framework. For commitment there's hearings with judges and legal council for the patient which meets the requirements the Supreme Court has laid out.

Qantourisc• 9 years ago

The choice here is (maybe there is a grey-scale here, but I don't see it): either you accept oppression and forcibly commit them (under certain conditions), or you value freedom and let them be if they choice to. The only general consensus seems to be: when they don't break any laws (or endanger other people).

Fricken• 9 years ago

Nature doesn't deal everyone the same hand. Society says we should all be treated equally. The laws of nature are absolute. The laws of society are made up, and exist only in our minds. The mentally ill and chronically homeless really bring out the dissonance between these two systems. We can exasperate ourselves and flounder about helplessly. We can leave these broken people on the street. We can round them up and put them in a junkyard, out of sight and out of mind. Or we can pretend we can fix them up and get them working again, even though we can't. About once a week or so the solutionists of HN go through this routine.

fpgaminer• 9 years ago

One of my friends was mentally ill. I had known him for years, but never knew about the illness. It wasn't until a cataclysmic event which resulted his suicide that I gained first hand experience with ... the tragedy of these broken minds.

He was an incredibly intelligent and accomplished person, but, like all of us, had his demon. For him, it was robo-tripping; taking large doses of cough syrup to get a high. It had been going on for years, maybe even decades. The years of abuse manifested as a hidden mental illness; he had concocted an imaginary friend who he could visit whenever he was tripping. The two of them grew very close together. The relationship was complex, as was this imaginary person. For all intents and purposes it was another "intelligence" living inside him.

Eventually he tried to cut his "addiction". But when he tried to stop cold turkey, he realized not taking the drug anymore would mean never seeing his friend again. By this point, he had grown too attached. So he continued his now ritualistic highs.

One day he was taken to the hospital for attempted suicide. Amidst all of this was an underlying chronic depression. The depression predated the abuse, likely your classic case of the depressed genius. He was released very quickly, I think within 24 hours or so. But now more of his close friends, including myself, knew something was up. I had no idea any of the aforementioned abuse was going on, nor the extent of his depression (I knew he suffered, but didn't know it was bad).

After that event, he sat down with me and told me everything. It was a long, shocking conversation. The evening after was one of those cold nights you don't think you'll ever escape from. Like being lost at sea. At one point he showed me a bag. It was filled with pills; gel capsule cough syrup pills. Probably about two fists' worth of the stuff. He said that was his dose for later; the kind of dose he always takes.

I didn't say much. What could I say? He talked about everything; the drug, his friend, the hospitalization. When it was all over all I could do was hug him and tell him I was always there for him if he needed. He wasn't the kind of friend I hugged; we were more intellectual buddies. In fact, that may have been the only time I've hugged him. But, I think, despite my mind whirling from everything I had just heard, somewhere deep inside I knew ... this might be the end.

The next few days were tense. Our mutual friends talked over what to do; we began seeking advice on how we could get him help. Could we "commit" him to get mental help? By this point, he didn't want help.

During the long conversation with him, he talked about the hospitalization. How violated he felt by the event; being forcefully taken, poked, prodded, drugged, and held against his will. In many ways I had looked up to his man; he was older and smarter than me. So when I racked my brain thinking about whether we should force him to get treatment ... I just didn't know what was right.

When he wasn't under the influence, he was more or less normal. And if he did get treatment, he would lose his imaginary friend. I know that sounds weird. I could never describe this "imaginary" person the way my friend told it to me. But, you know how someone will be telling you about a person they've been hanging out with, and just by the way they talk and the look in their eyes you know they're in love (but don't realize it)? It was kinda like that.

So I could see his position. If he felt that strongly about this "illusion", how could I forcefully take it away from him?

It was only a few days before everything was over. He committed suicide. We didn't get him help in time.

I'm still not sure how I feel. Should we have more aggressively sought to force help upon him? Should I have said something during that long confession of his; protest his actions, tell him to get help ... or ... something?

And in general, what should you do when anyone is in a position like this? Clearly mentally ill, but so delusional that they don't want help ... what is the right move? Should we force help on them, like this article discusses? My friend's case would have been a little easier; he was a danger to himself. But I don't think the situation is any more clear cut.

I just wanted to share my story. I don't know if many people have had to face this kind of stuff first hand; had to make these kinds of choices. Or, at least, I hope most haven't had to. It's been many years since it all happened. I still cry sometimes when I think about it. I don't envy the workers who go out in the streets and try to help the lost and the homeless.

raphlinus• 9 years ago

Thank you for sharing the story of your friend. It brought tears to my eyes.

Feeling guilt about not being able to do more is a natural consequence of suicide. But it sounds like you were there for him, able to really listen. Think of how many people struggling with these sorts of problems don't have that.

Nomentatus8• 9 years ago

There's no magic wand, dyfunctional brains are unpredictable. If you're just a friend, what might work one day (or moment), might be a disastrous approach the next. You made your best guess, and had no power greater than to do that. (Government remedies are perhaps another matter.)

bbunix• 9 years ago

The key here is "refusing help". In the US it's pretty well one of our basic rights unless we're a danger to ourselves or others. There are really only 2 choices, establish enough trust to encourage the person to receive help, or wait until their behavior violates the law, at which point they've forfeited certain rights and treatment of some kind can be mandated.

This process has mostly been used on addicts and alcoholics (treatment or jail, drug courts), and sometimes works.

Here in Key West, you can also get a bus ticket somewhere else, presumably where the person has more of a support system (family, friends)... if you agree not to return. This solves the problem for Key West, anyhow :)

marojejian2• 9 years ago

Better data would dramatically improve this situation:

- Statistical data on who is homeless and why - Data on how a given person's homeless life tends to proceed over time - Data from homeless people on how they view their lives + their "satisfaction" (whether they are mentally ill or not" - Data that attempts to predict health / satisfaction in the future from past circumstances

I'm sure some exists... but I don't hear much about it.

The article points to the value of data, by indicating that compiling a consistent history (across service providers) of a homeless person's history can make it very clear when someone is in the (extreme) case that they are not going to take good care of themselves in the future.

The (wonderful) discussion on this post goes through all the complexity of balancing respecting autonomy with promoting well-being. But even the best comments are anecdotes. I don't know if the greater evil (today) would be a) allowing people to destroy themselves or b) imprisoning them in a bureaucracy.

Understanding with data (top down overall + longitudinally) could give a sense for where the common cases are, and what cases we consider are very rare.

In criminal justice, we imprison innocent people. It sucks, and we will try to minimize it, attempting to "let 10 guilty people go free vs. convicting one innocent" But we don't go so far as to imprison almost no one.

By analogy, with better data, I would feel more empowered to have an opinion of what direction to push in here.

What to do with mentally ill homeless people who refuse help?

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