Murphy Bill Controversy
December 9, 2015 11:07 AM   Subscribe

Mental Health Groups Split on Bill to Overhaul Care: "The result: more people treated earlier, and more treated against their will." A Psychiatrist Opposes The Murphy Bill and Here's Why.

While Congress Eyes mental health overhaul in the wake of gun violence, others ask whether evidence points to mental health as the leading cause of America's gun violence problem. Is there a link between gun violence and mental health?

Some have concerns the bill favors forced treatments that ignore evidence based treatments outside the pharmaceutical model of care.
posted by xarnop (62 comments total) 22 users marked this as a favorite
 
That HuffPo op-ed is written by Leah Harris, chair of the National Coalition for Mental Health Recovery, an organization that opposes all involuntary interventions for people suffering from mental illness, even those who are a danger to themselves or who have a history of violence; and which believes that the seriously mentally ill should only receive care from their own special-care employees rather than medical professionals. NCMHR's own website scoffs at the notion of 'evidence-based practice' and claims that whatever any individual believes worked for them is the real evidence.
posted by shakespeherian at 11:19 AM on December 9, 2015 [39 favorites]


I just buried a family member because his mental illness got in the way of him effectively taking daily medication for a very treatable non-psychiatric disease. If we could have forced him into treatment, I'm positive it would've saved him. So I don't have a lot of sympathy for those against treating someone against their will because fluffy, squishy reasons.

Now, the psychiatrist in the Here's Why link is correct to say, "I believe we all know that we should not enact law based only upon anecdotal evidence." So, I respectfully invite her to count up all the homeless folks out there that were tossed out of psychiatric facilities in a combination of ruthless budget cuts and boneheaded advocacy.
posted by Cool Papa Bell at 11:24 AM on December 9, 2015 [6 favorites]


CPB: I'm sorry for your loss.
posted by shakespeherian at 11:25 AM on December 9, 2015


Yeah, huffpo tends to bring in something sketchy doesn't it? I was trying to go with known websites since I was told special interest sites were less valuable, however not that many were doing current coverage and she at least broke down some of the recent happenings. So I threw that one in at the end, although maybe I should have gone with a Mad in America link. I figured that would bring in it's own controversy as well, but I didn't know Leah Harris background would bring in the same controversy.

It's a good controversy to discuss though anyway. Most mental health reform advocates that I know do not have an extreme position on banning all forced treatments, however most agree the bar should be higher than this bill allows and the treatment options should include a variety of options, that do indeed account for the higher response rates some patients have to therapies like emdr or trauma focused CBT for trauma and other issues.

I too am sorry for your loss CPB.
posted by xarnop at 11:29 AM on December 9, 2015


I am very grateful my brother was committed and medicated. He would be dead otherwise.
posted by cairnoflore at 11:39 AM on December 9, 2015 [1 favorite]


I figured that would bring in it's own controversy as well, but I didn't know Leah Harris background would bring in the same controversy.

I think the issue is that while the Murphy bill is certainly far from perfect, it seems that the only folks who outright oppose it are just this same kind of anti-science self-determination-even-during-psychotic-breaks crank characterized by NCMHR and Robert Whitaker. NAMI, for example, expresses some misgivings, but on the whole are in favor of the bill. The same seems to be the case for all the non-cranks I can find or to whom I pay attention.

You may have trouble putting together a non-crank overview of objections, in other words.
posted by shakespeherian at 11:42 AM on December 9, 2015 [5 favorites]


Actually, my family was able to forcibly treat a family member during a severe manic episode. The whole process made me realize that forcible treatment isn't as uncomplicated or as unambiguous a good as people imagine - even though it worked, eventually, for my family.

Another thing - I also remember the forcible treatment of a couple of my depressed peers when I was in HS, and that it was part of abuse by their families. One was "treated" for being queer, one was just getting kicked around a lot and forcibly institutionalized in a crummy situation.

I'm not sure where I stand on this particular bill, or on forcible treatment in general, but I do know from personal experience that a lot of people have a fantasy about being able to treat an ill relative and having it work. Things we ran into: getting doctors to concur that my relative was actually ill enough to need treatment; stereotypes about old women which hindered accurate diagnosis and acceptance that she needed treatment (ie, old ladies are just kind of crazy anyway, nothing to see here); difficulty in finding a good place to take her because we live in a country with bad medical care. And we were very fortunate in general - my relative's condition proved to be very, very treatable and she quickly returned to herself and even regained some health ground.

The blog post that was posted yesterday and then taken down actually raised some really interesting points about the percentage of people who respond well to drug treatment for extreme psychological conditions - apparently about one in three respond well with no unbearable/major-health-issue side effects. Another third respond but have grave side effects, and another third don't respond at all.

The post also attempted to sketch out what forced medication would look like - in theory, there's an "outpatient" option where, basically, you are supposed to show up at the clinic for your meds and if you don't show up the cops take you and forcibly medicate you. In practice, we don't have the cops, much less the right kind of cops, and people have to be inpatients.

Forced treatment in an emergency over the short term is a very different ball game from forced treatment over the long term.

The post also talked about how the people who testify to the efficacy of forced treatment are, obviously, the people for whom it has been the most effective - and how those tend to be the most socially advantaged people, and the people with the most manageable conditions.

In 2002, Swanson repeated his study over the course of the year, tracking eight hundred people in four states who were being treated for either psychosis or a major mood disorder (the most severe forms of mental illness). The number who committed a violent act that year, he found, was thirteen per cent. But the likelihood was dependent on whether they were unemployed, poor, living in disadvantaged communities, using drugs or alcohol, and had suffered from “violent victimization” during a part of their lives. The association was a cumulative one: take away all of these factors and the risk fell to two per cent, which is the same risk as found in the general population. Add one, and the risk remained low. Add two, and the risk doubled, at the least. Add three, and the risk of violence rose to thirty per cent.

What would "forced treatment" look like for poor men of color? My relative was brought in for treatment by the cops, and in her delusion she threatened one of them. If we were a poor family of color, she might have been shot in front of our eyes.

I'm not saying that this is some kind of unpossible problem to solve, or that there aren't substantial benefits to being able to treat seriously ill people who are in crisis and unable to care for themselves, or that people should just wash their hands of gravely ill family - we didn't, even though it was a pretty horrible process on every level. It's just that it is an issue that is a lot more complicated and a lot less of a panacea than I think we'd like to believe.
posted by Frowner at 11:46 AM on December 9, 2015 [44 favorites]


I was told special interest sites were less valuable

Your "A Psychiatrist Opposes The Murphy Bill and Here's Why" link is to an advocacy/activist organization that appears to solely exist to oppose the bill. Which is fine, but I think it's definitely worth noting that it's from a one-sided source rather than a more evenhanded news article.
posted by zarq at 11:49 AM on December 9, 2015 [2 favorites]


Cpb, I'm sorry for your loss.

The bill sounds like a good thing overall. Given that involuntary commitment often takes the form of prison time these days, better to have it done in a hospital.
posted by Sheydem-tants at 11:51 AM on December 9, 2015


CPB, I'm so sorry for your loss. :(
posted by zarq at 11:52 AM on December 9, 2015


Another difficulty I ran into is that I've been reading articles from mental health advocates that do not have an "anti-psychiatry" stance for a long time, but I'm not that good at finding them from memory.

Now that I remember the search term consumer advocates, here are a few more mental health advocate groups that have been expressing concern like Mental Health America who say "Mental Health America also rejects the expanded use of involuntary treatment—ignoring the rights of persons with mental health conditions to make decisions concerning their treatment or minimizing the dignity, autonomy and self-determination of persons affected by mental health conditions. We believe that involuntary treatment should only occur as a last resort and should be limited to instances where persons pose a serious risk of physical harm to themselves or others." And Coker, director of the North Carolina Consumer Advocacy, Networking, and Support Organization, said "the bill might make legislators feel like they’re “doing something” about addressing the need for better mental health services in the U.S., but that the bill heads in the wrong direction."

While the issue requires nuance, if you've gotten the impression that it's only anti-psychiatry extremists who have concerns than I haven't done this issue justice.

I'll let ya'll carry on from here as I've done as well as I can.
posted by xarnop at 11:57 AM on December 9, 2015 [7 favorites]


I find the reporting on this bill really frustrating. I cannot tell, from anything I have read, whether this is an actual expansion of funding and care (leaving aside the involuntary care for a moment), or if it one of those bills that sounds like it expands care only to find out none of us understood how our clinics and hospitals are funded and so it turns into a massive cut.

As for the involuntary outpatient care, my only point of reference is Florida's Baker Act, which seems like a pretty good thing to me...much better to be admitted to the hospital for a day or two than be put in jail while your crisis gets worked out, or worse, left on the street. On the other hand, voluntary outpatient care seems to be pretty thin on the ground unless you've got excellent insurance (including Medicaid), so where are they going to find enough resources for involuntary commitments? There are that many outpatient treatment centers able to take on more patients? Or will they just be hospitalized when there are no outpatient resources?...and if so, where?
posted by mittens at 12:16 PM on December 9, 2015 [1 favorite]


I have pretty mixed feelings about involuntary treatment of people who are considered a danger to themselves but it does seem like you have to have a better mechanism for dealing with people who are a danger to others than jail provides.
posted by atoxyl at 12:22 PM on December 9, 2015 [2 favorites]


I'm not informed enough to have a firm opinion on this bill, but it's stories like this that give me grave misgivings about forced treatments:

The Missing Generation
For decades, Scott had struggled to find his place in the world. Misdiagnosed with schizoaffective disorder and manic depression (now called bipolar disorder), he spent much of his life in and out of group homes and psychiatric institutions, often heavily medicated: At one point, he was taking 18 pills a day.
I was misdiagnosed several times before I was finally diagnosed as being on the spectrum, first for bipolar disorder and second for borderline personality disorder. I wasn't a threat to myself or others but I was definitely quite unstable as a young adult, and my family has so few boundaries that I have no doubt they would have had no problem interfering in my treatment "for my own good." The very idea of having fewer roadblocks to forced treatment and/or institutionalization in that situation is enough to give me nightmares.
posted by dialetheia at 12:23 PM on December 9, 2015 [18 favorites]


To counterbalance the "only cranks oppose this bill" idea:

Ari Ne'eman: Mental illness: an easy scapegoat for those who won't point fingers elsewhere
Politicians who propose Medicaid cuts while arguing that the Murphy legislation is the solution to our gun violence problem seem to believe that the problem with mental health in America today is a lack of coercion, not a lack of funding. Their proposed policy recommendations suggest that they believe that we can cut funding and improve services, simply by depriving Americans with psychiatric disabilities of their right to decide how they receive care and who gets to know about it.
David Perry: If you care about mental health, know this - the Murphy Bill is the worst way to go about improving it
Unfortunately, while the Murphy bill won’t make us safer from gun violence, it will erode civil liberties and increase stigmatization. Even people who are in favor of court-ordered drug regimes and other outpatient treatments do not argue they are effective violence-reduction strategies. Such forced compliance also doesn’t lead to recovery.

“This is out and out promotion of irrational prejudice based upon disability,” Mike Bachluber, Co-Chairperson of National Council on Independent Living ADA/Civil Rights Subcommittee, told me about the bill. Robert Bernstein, president and executive director of the Judge David L. Bazelon Center for Mental Health Law, said that Ryan’s bill is not only “misguided” but “fails to address the real problems in the mental health system.”
Anne Penniston Grunstead: The Republican Solution To Mass Shootings Is Bad Mental Health Care Reform
My opinion is based on my years of searching for adequate mental health treatment for my own depression and anxiety. At my lowest points I was diagnosed with catatonia and psychotic features. After numerous inpatient stays at multiple hospitals, a string of outpatient programs and private therapy, I am recovered. I will always be on medication and I must be extremely vigilant in responding to early warning signs of depression or anxiety, but I live a happy and productive life.

Given what I have seen during this journey, I cringe when politicians and private citizens alike appeal to the importance of giving the mentally ill “help.” There is a very naïve belief that pushing someone into the hospital system or placing them in the care of a mental health professional will magically “cure” what ails them. However, many of these solutions are temporary at best and detrimental at worst.
posted by Lexica at 12:27 PM on December 9, 2015 [21 favorites]


People who think that it's *obvious* that people should be treated involuntarily would benefit from learning more about the history and complexity of this issue. Taking away someone's civil liberty and acting on their behalf is a *big* decision and needs to be the subject of lots of scrutiny. Someone's right to decide what to do with their life is a sacred principle of liberty and should be suspended only as a last resort.

Remember that lobotomies were considered "evidence based" treatment -- indeed, Moniz was given a Nobel Prize for his work developing the procedure. Tens of thousands of these were performed on unwitting patients, as was insulin shock, electric shock, and other, at the time scientifically validated therapies.

I *totally* get the heartbreak and pain that families (my own included) suffer when a relative dies because of a virulent mental illness. And I also totally get the urge and need to treat involuntarily sometimes. San Francisco has just implemented "Laura's law," which mandates such treatment under certain circumstances, and it's a big deal. Many people will be looking at the processes and the outcomes. It's just that no one should think that involuntary commitment is without serious risks, or that it's a magic bullet. Indeed, some studies suggest there's little or no benefit.
posted by jasper411 at 12:29 PM on December 9, 2015 [25 favorites]


It's incredibly frustrating for involuntary treatments to come back in vogue when no meaningful effort has been made anywhere in the country to provide adequate out-patient, voluntary mental health services. Many of the homeless mentally ill that people like to talk about could live stably in supportive housing with case management. One of the best articles on this point is about Andrew Goldstein, the man who pushed Kendra Webdale in front of a subway, leading to New York State's involuntary outpatient commitment law. No one can really say if Goldstein could have lived safely in the community with proper treatment, because it never happened. He sought help over and over, was hospitalized short-term, and discharged with no support or services. He's obviously an extreme example because he did end up killing someone, but ultimately I don't think his story is one that supports the need for more involuntary services.

I'm not a mental health professional, but I've worked with seriously mentally ill people for 11 years as a legal services attorney. I've had clients who benefited from involuntary hospitalization and involuntary medication, so I am not opposed to them. But throwing up our hands and saying "welp, deinstitutionalization didn't work" is lazy and dishonest, because a real effort at deinstitutionalization--with community treatment and services--has never happened.
posted by Mavri at 12:32 PM on December 9, 2015 [51 favorites]


On the other hand, voluntary outpatient care seems to be pretty thin on the ground unless you've got excellent insurance (including Medicaid), so where are they going to find enough resources for involuntary commitments?

That's my question too. I've been trying to find (voluntary) treatment for a child - with insurance and in a major city - and it is incredibly stressful and time consuming just to find someone who is (a) accepting new patients; (b) hasn't left the practice since the last time the insurance company updated their records; and (c) has less than a 2 month waiting period. I can't imagine trying to do this in a small town or without the insurance or money to pay for treatment. I guarantee there are adults out there needing forced treatment today just because their families couldn't manage to get voluntary treatment while they were children.

The vast majority of child psychiatrists and psychologists in my area (and I believe this is true of adult providers too) are foreign born. So I'm wondering why U.S. doctors are not going into psychiatry? If this bill doesn't somehow find a solution for that, I can't see that it's going to make much difference.
posted by Dojie at 12:33 PM on December 9, 2015 [2 favorites]


What a respectful, thoughtful discussion we're having here on mental illness! Yay Metafilter! Thank you!
posted by Melismata at 12:43 PM on December 9, 2015 [8 favorites]


So I don't have a lot of sympathy for those against treating someone against their will because fluffy, squishy reasons.

I am so, so sorry for your loss. I also have made the decision to subject a family member to involuntary treatment without which he might be dead and I have read quite a bit about this. Any given person's right to bodily autonomy and control over their own health—even in defiance of what we think to be "reasonable" or "competent" or "right-minded"—is actually quite a hard stop, neither fluffy nor squishy. It's when we treat rights as an abstraction that it's easiest to erode them.
posted by listen, lady at 12:48 PM on December 9, 2015 [6 favorites]


Dojie, the docs who used to go into psychiatry wanted to do therapy, but psychiatry has morphed into a biological specialty that emphasizes very short visits and trying one medication after another with the hopes that something will help. If you don't fit into that pattern, your reimbursements will go down, way down. So a lot of current practitioners are unhappy with the field, thus leading to shortages as they retire.

This has led to a lot of interest in non-medically trained people (especially psychologists) trying to get prescribing privileges. I haven't paid a lot of attention to this for a while, and I believe it is the case in a few states and in some pilot projects. But the medical associations are *entirely* opposed to these efforts and fight back against them hard. The reason behind their opposition is probably at least in some part turf and guild related, but they also express concern about giving prescribing privileges to people who have not had years of medical training. The psychological associations have been working on creating training curricula, but there are also psychologists who are not in favor of prescribing. Medications are not a panacea either.
posted by jasper411 at 12:51 PM on December 9, 2015 [2 favorites]


While there is a lot to be wary of, the example above of an older white lady being threatening to the police while having mental issues and the comparison to the potential issue with people of color, it might be (with all the obvious caveats) a better direction for the primary response of a person acting crazy of any color or persuasion to be the hospital rather than the morgue.
posted by sammyo at 12:56 PM on December 9, 2015


But when did the medical oath morph from "first do no harm" to first medicate?
posted by sammyo at 12:58 PM on December 9, 2015 [1 favorite]


Oh man, has anyone else here ever been consumed with compulsions, obsessions and intrusive thoughts and nestled amongst those keeping you from getting help was the thought that when the folks found out what you were really thinking and feeling they'd strap you down and lock you in some dungeon and your life'd be over?

I lived that. Those were some tense negotiations even getting a conversation started. I've been on the other side of that too, telling people "naw man, they won't lock you up and throw away the key if you try to get help."

My experience in life has been that it's pretty dang hard to get psychiatric care when I go looking for it. Even having some significant DXes unless you're about to acutely hurt someone or something, it can be hard to get seen. Of the 6 or so folks I've seen for various issues in the past decade I'd only trust one (maybe two) to make the call to have me committed and the rest were just way too checked out to trust with a decision like that.

I'd say my preference would be focus on increasing access to (and quality of) voluntary treatment. Particularly given the difficulty in getting involuntary commitment "right" in terms of respecting patient civil rights and mitigating opportunity for abuse.
posted by Matt Oneiros at 1:02 PM on December 9, 2015 [24 favorites]


Even with private insurance and resources to pay for treatment, inpatient treatment is often not readily available, at least not here in Chapel Hill, NC. So if they are going to force people into involuntary treatment, where are they going to put them? Just warehouse them all in a room and shoot them full of Thorazine? I live in a relatively wealthy area and we don't have the infrastructure to take care of lots of new psychiatric patients. What on earth are they going to do in the poor areas?
posted by tuesdayschild at 1:03 PM on December 9, 2015 [9 favorites]


Thanks for the post, xarnop. And thanks Frowner and Mavri, especially for your comments. I feel like this gets to the heart of my feelings on it:

It's incredibly frustrating for involuntary treatments to come back in vogue when no meaningful effort has been made anywhere in the country to provide adequate out-patient, voluntary mental health services.

I am incredibly lucky for my family situation and their financial/emotional support and I attribute that primarily for the reason that I am a generally healthy and generally functioning adult today (I was never violent but like some of the articles mention the 'violence' issue is sort of a hand-wavey way to shift blame off of guns, etc.).

I was incredibly close to committing myself when I was at my worst until basically by chance an old doctor checked in on me and very vaguely tipped off my parents that things were very wrong. I was, absolutely, critical--hearing voices, suicidal, etc. etc. Thing is, when my parents swept in, we were initially told it would be over a month before anyone could see me on an outpatient basis, and frankly even though I would probably have been willing to do it, committing myself/being "institutionalized" as a concept terrified me. We got lucky in that either someone cancelled or my parents begged to get me in to see someone and we got in within a couple of days. But again... we had the resources, I had the support network. If I didn't have the right insurance or the right family I wouldn't be that lucky.

I guess the big one I see that really worries me is this:
"AOT is a euphemistic term used to describe involuntary outpatient commitment ordered by a judge, with the threat of involuntary inpatient hospitalization for those who do not comply with their treatment orders. H.R. 2646 dramatically lowers the current standard for involuntary treatment --danger to self or others-- to include people with a history of hospitalization or a history of not complying with treatment."

I went through a couple of misdiagnoses and bad medication choices before things got sorted out. That's not at all rare when it comes to treating mental illness. When I brought up concerns/objections about my medication I wasn't outright told not to worry about it but I was discouraged from questioning what was happening with me. To be brief, it was bad--I wasn't sleeping (I'd go 2-3 days without), I literally could not stop talking, I was forcibly and violently 'happy' in a weird, hollow way, the point is I knew it was fucked up. It was terrifying and I was miserable. Close family sort of noticed but I don't think they really caught on 'til after the fact... but I think it seemed like I was 'better' in that I wasn't suicidal and didn't seem depressed all the time. I stopped taking the medication as a last resort because I felt like I wasn't being heard, and ultimately we stopped seeing that doctor. I seemed 'better' enough for a while that we didn't see another one until things got really bad again.

I guess my worry is, could someone like me (and again, this isn't uncommon) have ended up in involuntary outpatient commitment because I was "not complying with treatment"? And if so, what exactly would be my recourse for getting off of a medication that was really, really bad for me? Would I just be stuck on it forever unless I could get a doctor that would actually listen?

Anyway. The bill in its current form concerns me because of a few things like that. This is the first I've seen/read of it though and I'm really glad it's been brought to my attention. I'll have to read more of the links that've been contributed to the thread while I was typing this junk up and see if I can get more/potentially better/less-biased perspectives from those.

great post, I think you did really well. thanks!
posted by suddenly, and without warning, at 1:27 PM on December 9, 2015 [21 favorites]


One of the best articles on this point is about Andrew Goldstein, the man who pushed Kendra Webdale in front of a subway, leading to New York State's involuntary outpatient commitment law. No one can really say if Goldstein could have lived safely in the community with proper treatment, because it never happened. He sought help over and over, was hospitalized short-term, and discharged with no support or services. He's obviously an extreme example because he did end up killing someone, but ultimately I don't think his story is one that supports the need for more involuntary services.

Holy shit Mavri, that's an amazing article. Thank you.
posted by Melismata at 1:36 PM on December 9, 2015 [3 favorites]


In a rush & will comment more thoughtfully later after RTFAing, but came to really really really second Frowner:
It's just that it is an issue that is a lot more complicated and a lot less of a panacea than I think we'd like to believe.

QFMT. I'm bipolar, runs in my family, a family member was institutionalized back in the 'snake pit' days. Not only was I med compliant for all of my hospitalizations except the first, in at least 2 incidents I know for certain the meds were what made me have a psychotic break. Like, can't remember my last name, delusions of persecution/delusions of reference psycho. This is not uncommon by the way; I'm in a few online BP groups and this is a very common refrain.

Doctors don't always know what the meds will do and they tend to not want to admit errors in judgement or lack of knowledge out of hubris and/or CYA lawsuit protection. So sometimes they'll insist it's YOU, or malingering or whatever... not the meds...ugh. It's a rabbithole of maddening bullshit, I tell you. You sometimes have to bring in an article and say "Yeah this one's linked to violence in major studies, so I'm not taking it anymore", then yes, they'll change your prescription because now they're afraid of a lawsuit or some other professional fallout. I know people who became psychotic and hallucinated on Seroquel, an antipsychotic. The science is just not that reliable, (not to mention the drug companies) nor is the brain that predictable. I had a very bad reaction to Effexor, which was great until is wasn't great and it made me go nuts. Just like Paxil did. You will hear thousands of these stories if you are in mental health support groups, even while you have a doc telling you it's Just You.

Sometimes the cure is half the problem, sometimes it's worse. Much of psychology and psychiatry is a fucking educated-guessing game and you get to be the lab rat. So yes-yes, patients' rights in decision-making. Don't assume that the meds will be right for you or them or that the doctor is all-knowing. It would be nice if it worked that way but 30 years of this has taught me differently.

Having worked with homeless people, I can say that some of them are on meds, they just don't work that well, and/or they don't have access to consistent, high-level care, and they have other problems like PTSD that complicate matters. They're on basic maintenance of 'treat & street'. Mainly, they lack the social & economic supports to keep them out of deep water. And I live in a city with excellent social services infrastructure.

So yeah, panaceas, not so much.
posted by GospelofWesleyWillis at 1:51 PM on December 9, 2015 [13 favorites]


So sometimes they'll insist it's YOU, or malingering or whatever... not the meds...ugh. It's a rabbithole of maddening bullshit, I tell you

Oh, I'd say it's a wild abuse of power.
posted by listen, lady at 1:53 PM on December 9, 2015 [4 favorites]


I do civil rights policy work for a disability-led disability rights organization, and people with disabilities -- mental health, physical, behavioral, developmental -- are very strongly opposed to this bill, because it places the human cost of our broken support system and social safety net precisely on to people with disabilities.

Rather than provide services that can and do help people to live successfully in the community, the Murphy bill dramatically lowers the bar to just locking people away. This is, itself, a violent approach to mental illness and disability: it treats as acceptable losses the rights of people with disabilities to live in the community -- a right that non-disabled people who have not broken the law take for granted as fundamental to their existence.

I was at an action this spring in D.C., at which a young woman told the story of her life in an institution. She said that while she was institutionalized, she saw others in her ward whose bedsores became so severe that they had maggots growing in them. I say "young" because I guess she was in her early to mid twenties: this is not something from the bad old days.

In an institution you do not have control over who enters your room and touches your body. In an institution, they bathe you once a week -- if you are awake when they come to bathe you. Nobody in this thread would ever willingly rent from a landlord whose lease allowed the landlord to send his employees into your room at any time of the day or night and touch you, move you, or medicate you if you misbehave. And if you are in an institution, you are probably not making rent at your old place, you are almost certainly not working or receiving a housing stipend, so you really have no place to go. The power dynamic is open to incredible levels of coercion and abuse, and it takes years to get out and into the community.

Making it easier to institutionalize people with disabilities to make non-disabled people safer is some Ones who Walk Away from Omelas shit.
posted by gauche at 2:01 PM on December 9, 2015 [30 favorites]


Like so many other things in America, there are about twenty different solutions all of which might be pretty effective most of the time, except they would have to be adequately funded, sufficiently staffed and implemented by people who were not driven by cruelty, power-hunger and the belief that the issue under consideration represents a dangerous character flaw. But because we can never have any of those things except in very occasional, very tiny projects, people will just continue to suffer.
posted by Frowner at 2:03 PM on December 9, 2015 [10 favorites]


I'll just add my voice to the chorus asking where the resources are for voluntary treatment. That's the easier version of the problem; why don't we do that one first?
posted by PMdixon at 2:15 PM on December 9, 2015 [8 favorites]


this is not something from the bad old days

Relevant: NYC Hospital Uses Forced Medication to Compel Bloodwork
posted by Mavri at 2:18 PM on December 9, 2015 [2 favorites]


It's not surprising that this bill focuses on involuntary treatment and crisis response rather than improving access to voluntary treatment. It's only come up because of people blaming mass shootings on mental illness. We, as a country, are not particularly interested in helping the masses of people who are struggling (with mental illness, drug addiction, poverty, trauma, whatever), so much as in protecting ourselves from the few who become a threat to us as a result of those struggles. We'll try to control the troublemakers but everyone else is left to fend for themselves.
posted by Dojie at 2:23 PM on December 9, 2015 [7 favorites]


Here in the upper-left-hand corner of the US, the conversation over involuntary treatment predates the rise in mass shootings over the past 3 to 5 years. It is very difficult/nearly impossible to get involuntary treatment for family members who are a danger to themselves or others.

Adding resources for voluntary treatment is great and necessary, but this bill isn't directed at the problem that an increase in access to voluntary treatment will solve. Voluntary treatment on every corner is useless if the mentally ill person is unable or unwilling to make the choice to get treatment.

Blocking this bill because it doesn't make enough (it makes some for sure) of an impact on increasing voluntary treatment is like blockingg a rise in the federaal minimum wage because it doesn't also increase taxes on the wealthy.

Read the bill. or at least the summary. Perfect? Nope. Better than what we have, it seems like it to me. Hopefully it will get through in some form--maybe even addressing the concerns that some have raised about it (not the anti-science folks though--they can do that mumbo jumbo on their own dime, thanks).
posted by Cassford at 2:44 PM on December 9, 2015 [1 favorite]


Blocking this bill because it doesn't make enough (it makes some for sure) of an impact on increasing voluntary treatment is like blockingg a rise in the federaal minimum wage because it doesn't also increase taxes on the wealthy.

I feel like by focusing on this and with the rest of your comment you are ignoring the very real concerns that many people in this thread--many mentally ill people even--have re: overreaching with involuntary treatment. If you read most of these comments it's not just 'increase funding for voluntary treatment!', it's primarily 'the potential for abuse by lowering the requirements for involuntary treatment this much is massive and that concerns me' which is totally legit and valid and has a huge historic (and present, e.g. Mavri's link) precedent.
posted by suddenly, and without warning, at 3:04 PM on December 9, 2015 [13 favorites]


I feel like by focusing on this and with the rest of your comment you are ignoring the very real concerns that many people in this thread--many mentally ill people even--have re: overreaching with involuntary treatment.

Yeah, something that I recently read in a wonderful essay by a friend with a severe mental illness was this: involuntary treatment measures are as much and sometimes more for loved ones and family than for the people who are subject to them. And again, I stress that I do have experience with this, so this isn't a case of just not knowing how it really works. Involuntary treatment is traumatizing, full stop. Calculating that someone else can take an involuntary trauma for their own good—even if it is true and best!—is an enormous and costly and challenging decision.
posted by listen, lady at 3:20 PM on December 9, 2015 [12 favorites]


And: people with mental illnesses also have the right to autonomy over their (our) bodies and health care decisions, like virtually any other health care consumer, and the discourse of competence strips them (us) of meaningful choices. We have to figure out that can be communicated in ways that are respected & attended to. And sometimes it's shitty and you definitely don't have to like it. It is, nonetheless, true. Like I hate some radical mental health discourses, but I also can't deny some of the central claims about freedom.
posted by listen, lady at 3:23 PM on December 9, 2015 [8 favorites]


Better than what we have, it seems like it to me.

If I'm reading this thread a-right, the bill as it stands is potentially better than what we have for some, and potentially worse than we have for others. The former doesn't just make the latter go poof and disappear.
posted by AdamCSnider at 3:24 PM on December 9, 2015 [3 favorites]


Involuntary commitment is a bad outcome. It might be a necessary one in some cases but only because the foreseeable alternatives are worse. It's a lot like chemotherapy or surgery in that way.

Increasing access to voluntary treatment reduces the need for involuntary commitment. And right now in every region of the country, as far as I know, there aren't enough psych beds for the people who need and want to be in one.

Blocking this bill because it doesn't make enough (it makes some for sure) of an impact on increasing voluntary treatment is like blockingg a rise in the federaal minimum wage because it doesn't also increase taxes on the wealthy.

No, it's like blocking a poverty relief bill whose main mechanism was an increase in funding for the juvenile probate system.
posted by PMdixon at 4:14 PM on December 9, 2015 [10 favorites]


I'm a certified peer support specialist working at a clinic in the state of Oregon. I have met Leah Harris at a couple of the conferences I have attended. I'm not going to directly address her credibility (though I think it's valid given her lived experience with these issues) but I will say this - Murphy's bill certainly appears to be a way for a Republican congressman in a Red state to make a name for himself by diverting attention away from the gun's role in the mass shootings we have had to "all these were done by crazy people; it's their fault not the guns" and make it easier to put potential mass shooters away with the added "benefit" of getting all those strange looking/acting crazy folks off the street. It won't change a damned thing regarding mass shootings. They will still happen until we make a decision to reduce and manage intelligently the number of guns and who uses them and under what circumstances and why.

Regarding the position of forced medication/treatment, I am not totally against it but my own experience (including being forcibly committed once myself) makes me very cautious regarding it's use - particularly when the folks running the system who would be making the decisions are overworked and under equipped resource-wise to choose the best option for the desired outcome. In our state we have a hell of a time finding places for folks to go voluntarily; we lack beds and facilities and funding both for the facilities and for the folks who work in the system. A return to the old school way of treatment would be a disaster and would lead right back to the horrors of warehousing human beings and medicating them for management instead of recovery.

I am not going to wade into this discussion past this because I am tired after working today, but I wanted to say one or two things about it because the bill and attitudes behind it scare me and a lot of other folks like me who have been through hell with docs and meds from time to time and returned to society to tell the story. I have buried more friends due to meds and over reliance on them than I want to remember. The bill seems to be nothing more than a convenient red herring well timed to deflect efforts to pass reasonable gun control and reduction measures along with some social control measures the right has been pushing for a long time now.
posted by cybrcamper at 4:14 PM on December 9, 2015 [13 favorites]


AdamCSnider--good point. The ABA is opposing some provisions of 3717-- specifically the reduced funding of PAIMI. I wonder if Murphy is reducing the funding on policy grounds/philosophy or if it is just once again robbin Peter to pay Paul. Can't we have both?
posted by Cassford at 4:15 PM on December 9, 2015


I think we are all agreed that the bill have a very limited effect (if any at all) on mass shootings. But it seems that it could reduce suicides. And maybe a few one-on-one himiciides. It is all so very complicated. There are some studies that claim that the move toward the "dangerousness" criterion for involuntary treatment has actually increased the public perception that the mentally ill are dangerous persons and increased stigmaatization. That seems wrong to me, but it is an interesting notion. I know people in my family were committed throughout the 20th century and there was never a notion in the family that they were "dangerous" to anyone but themselves. "Sent away after a nervous breakdown" sounds like a need for R and R compared with "Adjudicated for mandatory treatment" or whatever the term of art is now.
posted by Cassford at 4:28 PM on December 9, 2015


Saying the bill is potentially better for some is being a lot more generous than the bill deserves.

The more institutionalized we make mental health care, the more people will drop out. If a diagnosis means losing civil rights, I will avoid treatment until I can't hide my symptoms any more. And there's family history of suicide, so it's not like I'm saying that while blind to the cost it might have.

The lives saved would pale to the number of people driven from care. Many of my friends have sought out mental health care at some point in their lives. Of the three who have committed suicide, one kept his diagnosis a secret, and the other two never sought out a diagnosis at all.

That's not to say that involuntary commitment is never the answer. But the circumstances need to be so dire that I would be grateful after the fact. I need to be able to trust the system that I rely on for care. This bill destroys that trust.
posted by politikitty at 4:44 PM on December 9, 2015 [13 favorites]


There's a lot of stuff in that bill that's... weird (aside from the involuntary commitment stuff which seems to be completely absent from the CRS summary).

In sec. 1152 the bill cancels any SAMHSA program not explicitly authorized by congress (what programs does that affect)?

In sec. 301 HIPAA is negated for "caregivers" of any adult patient that has any sort of significant DSM-V mental illness impairing any part of their life. Here, caregiver is defined as an immediate family member, an individual who assumes primary responsibility for any basic need of the patient (i.e. providing food or housing) or any personal representative as specified in state law.

In sec. 302 FERPA is negated for "caregivers" of a DSM labeled person (if they're a legal guardian, or the patient consents to the document release this is already possible) -- in this section the bill expands "caregiver" to any past legal guardian who has cosigned a loan.

I think for a lot of folks here it's very easy to imagine the types of abuses sec. 301 in particular would enable.

There's a lot of talk about evidence-based practices in this bill, but I'm unsure of how that would be operationalized under this bill (I didn't find any clear definition in the text itself) although CMHS is supposed to establish a clearinghouse thereof. The bill also explicitly enshrines in law CBT, RAISE and NAPLS as acceptable therapies -- why, and what if that changes as new evidence comes in? It'll take an act of congress, I suppose.

Also, while I'm not a huge fan of AA/NA/12 step programs, it's a widely accepted treatment that may not hold up to certain evidentiary standards. Would this change any current treatments folks are using? How would that affect them?

There's also an explicit ban on SAMHSA subsidizing any sort of treatment program which is not "evidence-based" -- does this have an effect on their ability to contribute to research?

Aside from appropriating some more funds and creating some new positions I found more to dislike than like in that morasse. Anyhow, having read the bulk of it, I'm still not sold.
posted by Matt Oneiros at 4:55 PM on December 9, 2015 [13 favorites]


listen, lady: "something that I recently read in a wonderful essay by a friend with a severe mental illness was this: involuntary treatment measures are as much and sometimes more for loved ones and family than for the people who are subject to them."

Indeed. In the David Perry article, he says "Notice how even in the title of this current iteration of the bill (it has failed to pass in previous Congresses), the emphasis is on families, not people with disabilities themselves."

Were any people with mental illness involved in drafting this bill? As the autism activism community says, "Nothing about us without us." Many mentally ill people are able, when not in crisis, to reflect thoughtfully on our own experiences and provide suggestions for how to better support us and to prevent or mitigate possible harm we might cause when in crisis.
posted by Lexica at 4:56 PM on December 9, 2015 [11 favorites]


This is a good thread, and although I don't think I have the wherewithal right now to fully engage with it, I want to say that I appreciate what people are saying here. It's a brutally hard topic.

I have been involuntarily committed to a mental health facility, briefly and as a juvenile. It probably steered me off an ugly path, by scaring me more completely than anything else I've ever experienced and teaching me to bury a lot of things lest I come to the attention of the system in any way that threatens my autonomy. Two decades on I have only recently stopped having nightmares about being caught back up by that whole scene. I should, probably, seek treatment for the depression that's almost killed me every three or four years during my adult life, but it has never seemed worth the risk.

I have to guess that a lot of the people I met during that little window of time 20 years ago are dead now, or living lives defined by inescapable desperation. I'm not going to say that I think no one should ever be subjected to involuntary treatment. I have met way too many people who are well beyond a capacity for self-care, and to whom I think society has a duty of care that is often completely unmet. Still, I really appreciate reasonable scepticism about confining and medicating people against their will.
posted by brennen at 6:24 PM on December 9, 2015 [10 favorites]


I think it's also worth noting that in the past, involuntary hospitalization has been used as a way for people to lock away their inconveniently uncompliant spouses and children, not to mention people the police didn't feel like dealing with again. This is not an uncomplicated good by any means.
posted by corb at 7:10 PM on December 9, 2015 [6 favorites]


My biggest problem with this is that we need good inpatient treatment. There are wonderful programs out there for people with tons of money, but the inpatient reality for most of the country is a holding cell with medication provided and a group room where someone talks very generally about disorders. A patient is lucky to see a therapist, because some opt for brief group therapy and call it a day.

I think if inpatient treatment took the time to allow patients more dignity while maintaining safety I think some of the stigma would disappear.

And fuck caregivers having access. My father would have killed me if someone told him what I was saying in therapy.
posted by AlexiaSky at 8:07 PM on December 9, 2015 [8 favorites]


Matt, what I've heard SAMSHA or the FDA are looking at defunding programs that are solely 12 step based and don't do any other interventions, as they want to find programs that are evidenced based and effective. I couldn't find a link on it though.
posted by AlexiaSky at 8:16 PM on December 9, 2015 [1 favorite]


The end of hitting rock bottom came across my feed this morning - about the use of CRAFT addiction protocols as a way to help families and addicts.
posted by dorothyisunderwood at 8:34 PM on December 9, 2015 [1 favorite]


I'm very glad for the discussion here, though I've only been skimming; the topic of involuntary treatment tends to put me on edge. Since I'm not sure I can talk about the Murphy Bill without losing my cool, I'm just going to make a few points and bow out.

so,

1. Involuntary commitment laws can discourage people from seeking help. For every person saved, there may be many more who never reach out because they fear commitment. At the darkest time in my life, my biggest fear was that talking to someone would get shrinks involved, eliminate my autonomy and the few social connections I still had, and would generally be worse than working things out on my own. I didn't seek professional help, and based on past experience and what I know about "mental health treatment" in this country, I believe I made the right choice. I will *never* willingly speak to a psychiatrist, and involuntary commitment laws are a big part of that.

2. Ex-patients don't protest psychiatry and laws like the Murphy Bill because they're anti-science cranks, they protest because they've been personally subjected to the 'benevolence' of involuntary treatment. Unlike family members, lawmakers, and ever psychiatrists, they know what it feels like to be involuntarily committed. Unfortunately, the rhetoric of mental illness makes the testimony of former patients suspect, unlike other situations where first-hand experience bestows extra credibility. People who have experienced psych hospitalizations have valuable things to say. Please listen to them.

3. Do you know how many NRA lobbyists worked on this bill? The answer is thirteen.

4. Involuntary treatment laws can empower abusers. Want your spouse, child, or elderly parent out of the way? Call them crazy and get them committed. This is a real concern, and once diagnosed, it is remarkably difficult to prove one's sanity.

5. The diagnostic categories in psychiatry are socially constructed and rather arbitrary. There are no objective tests for 'mental illness', and the DSM was formed by a bunch of comfortable, middle-class professionals, a majority of whom have ties to the drug industry, who decided by vote what are and are not normal ways to be human. Involuntary commitment laws grant the subjective judgments of mental health professionals (which are often made after very short periods of observation) the force of law. This is not scientific.

6. The claim that this bill will prevent violence is not supported by evidence. People diagnosed with mental illness are in fact more likely to be victims of violence than the perpetrators. Meanwhile, the Murphy Bill is quite likely to violate the civil rights of many non-violent people, simply so the public can scapegoat a feared and vulnerable minority into further marginalization. If we really want to help people, there are much better ways.
posted by Wemmick at 9:23 PM on December 9, 2015 [20 favorites]


Matt Oneiros, I'm concerned about the wide exemptions being carved out of HIPAA (and apparently FERPA) as well. Glad to see it's getting some notice.
posted by vsync at 11:45 PM on December 9, 2015 [3 favorites]


(if the hipaa changes pass, will i have to go through yet another excruciating webinar for training? please say no.)
posted by mittens at 4:24 AM on December 10, 2015 [1 favorite]


(Since I mention, way upthread, the story of getting a relative forcibly treated/briefly committed, I want to give a few additional details. She died some years ago and I don't think the details reflect badly on her. I just want to share what led us to make the decision we did and the social factors that contributed to her situation.

She was a remarkable woman who had a long career in a field where there were few women when she started out. She traveled widely, including behind the Iron Curtain in the seventies, when you were required to have a state "interpreter" to make sure you didn't go off path. Late in life she discovered that she loved cats and adopted several disabled strays. She had a teeny-tiny city apartment - the very smallest and cheapest pied-a-terre in a glamorous 1960s-modern highrise. Basically, she was cool.

She was diagnosed with bipolar disorder some time in the sixties, we think - she didn't tell anyone, because it was so heavily stigmatized. She was able to deal with her symptoms on her own and for many years was able to manage without medication, with the aid of a therapist. She must have had a lot of habits and practices that she didn't talk about. We don't know too much about this. She was both fortunate and tough.

When she was semi-retired but still doing a little freelance work, her health declined and she started to need more help. She had long-term care insurance that was supposed to cover a part-time carer, but they were screwing her around. She was very worried and couldn't sleep. The stress and lack of sleep (and possibly some other factors) triggered a really serious manic episode that was very shocking to us - she was threatening people and acting in all kinds of wildly out of character ways. It was much more severe than the manic episodes that another friend with bipolar has been able to deal with.

We didn't know what to do. She wouldn't see a doctor, she wasn't eating, she couldn't take care of herself and her physical health was very fragile. We got her to go to the ER once, only to have the world's stupidest worst human being resident tell us that she was just old and maybe she needed some vitamins. After that, she wouldn't go anywhere. We talked to her lawyer, we talked to some doctors at another hospital and we decided that we would try to do that three-day hold thing. We did all the required stuff. My impression was that it would have been difficult - under the local laws - to commit someone who was not in pretty dire straits, unless you had some crooked or bigoted doctors on your side.

We called the cops and asked them to help us bring her to the hospital. I hated this, because I do not trust cops and because I know that I, as a white person, can get help from them that is denied to people of color. When they arrived, she was threatening, but because we were white and from a middle class background, the cops accepted that she needed help instead of treating her as a threat. We went in the police car with them to the hospital and she was checked in. Some of this is a bit of a blur to me now.

I had come home from Minnesota to help out with this, which was fortunate because I was more familiar with medical systems. Luckily I had a job where I could take some vacation for this purpose.

As I understand it, the hospital primarily relied on mild sedatives and she slept for a few days, which pulled her out of the manic state. I think after that she had some kind of mild medication, but I don't remember which as I returned once her condition was back to normal. She got better very quickly.

The ironic thing - her insurance company, which had been screwing her around, decided that after this expensive, ruinous hospital situation and all her suffering, now they would approve funds for a carer.

She got back to herself, we were lucky to find a really nice carer who clicked with her and she was able, in fact, to do some of the things she'd enjoyed but hadn't been able to do for a while. After this episode, she was fully herself until her death - talking about culture and politics, reading, drawing a little, enjoying a very little dry white wine. She was able to make all her own medical decisions during the time that followed.

I stress that we were very, very lucky.

Some factors:

The social ones - if bipolar were not stigmatized, we might all have known about this, and we might have known how she wanted to be helped; we also might have been able to give a better medical history for her so that the world's worst resident would have had to admit her the first time. We would have been able to plan with her instead of flailing.

Insurance, obviously. While she was really fortunate in general, insurance-wise, if her insurance had paid up in the first place none of this would have happened.

Family and care - What were we to do? She wasn't safe to live on her own during this episode, we had no idea what it was or if/how it would end and she had a bunch of other health conditions. Without getting her treatment, our option would have been to have a family member stay with her 24/7 until....something. This was not a realistic possibility, even if we had removed her from her beloved apartment by violence so she could stay with family. Or, alternatively, we could have left her alone to live or die.

I think we made the best decision given the situation, and I don't see what else we could have done that would have made her happier. But I also feel like the factors that brought us to this situation were economic and social, and that if we didn't live in a society that was biased against mentally ill people and had really crappy health care, we would never have had to make the decisions we did.
posted by Frowner at 6:28 AM on December 10, 2015 [6 favorites]


Wemmick, thank you for that. That was excellent. Thanks also to people having a meaningful conversation in light of yet another "Lock 'em all up!" reaction to yet another shooting. 13 NRA folks in that bill? Goddamn if that isn't a smoking gun (pardon). That just says everything.

And good to keep in mind that the Aurora shooter was already in therapy, as was Isla Vista & more than one shooter has been on antidepressants at the time. (And the 2009 Fort Hood shooter was a psychiatrist) Also, it was discovered too late for some that antidepressants can actually cause suicidality, at least in children and teens. And no it doesn't make me anti-med or anti-science, just anti-wishful thinking for simple solutions.

I too am sorry for CPB's loss, but boneheaded advocacy, no, unfortunately, not by a long shot. What we might as well be frustrated and angry with is mental illness itself, not the fact that some people point out the major abuses and problems in treatment. Unfortunately, neither one of these things will go away quietly.
posted by GospelofWesleyWillis at 3:34 PM on December 10, 2015


I sure wish there was a bill to vastly expand voluntary and publicly-funded mental health services, incorporate and physically co-locate those service with physical health services, improve the actual physical infrastructure of existing mental health service sites, update those services to hold with current medical evidence, and finally to provide therapeutic and enriching day programs as well as robust community-based case management that includes home visits and system navigation services for people with mental illness.
posted by latkes at 4:49 PM on December 10, 2015 [7 favorites]


I've gone back and forth for a while about whether or not I wanted to comment on this thread, but all the people with lived experience who are speaking up have moved me a great deal.

The advocacy of a disenfranchised group is never bonehead, fluffy, or unnecessary. I think it's very easy, much too easy, when you yourself have never been hurt within the system, to assume that the things people are talking about here exist in almost a separate universe from you. That the bad things happened a long time ago when there were "madhouses", they're something that happens to your family member or your friend or someone you read about on the internet, but not to you personally.

I know that feeling because I did not understand the full scope of abuse within the psychiatric hospital system until it happened to me. Without going into detail, I was lucky enough to just avoid being forcibly institutionalized. I was not lucky enough to avoid, as listen, lady said, the inevitable and lifelong trauma that comes with having your dignity stripped away from you. People usually do not get better in places where they are denied all personal autonomy. If nothing else, it changes the way you see yourself and the world.

It is a challenge to go through life and not be sure if a person with otherwise very progressive politics just dismisses issues involving disability, but to prepare yourself for that dismissal because it is so common. Like most things involving mental health in the public sphere, the voices that most matter in these discussions are being lost. That begins with the discussions never even being centered on them in the first place.

The Murphy Bill terrifies me. The fact that any of this might not get better in my lifetime terrifies me. But it is enormously heartening to see that in whatever small way people with mental illness are pushing back against the cruelty imposed on us by even the people who should be our allies.
posted by colorblock sock at 6:06 PM on December 10, 2015 [8 favorites]


Also, it was discovered too late for some that antidepressants can actually cause suicidality

When we talk about evidence-based medicine, it is the history of antidepressants that frustrates me most. Because our doctors were making decisions based on bad evidence, weak evidence. We were being prescribed things whose success rate was nothing like what was promised, that had dangers that no one had studied well enough. Worse--and here I'll sound like a conspiracy theorist, but that's okay--you had scientology banging the drum about SSRIs being deadly, and I think the fact that it was part of their antipsychiatry propaganda was something that prejudiced people against the possibility for too long.

I'm not pointing fingers at psychiatry, really. I'm just saying, it's scary to need medicine, when you can't know if the evidence behind that medicine is valid, or if it will overturned in a decade.
posted by mittens at 6:51 PM on December 10, 2015


As a mental-health clinician, I have found that staying consciously aware of my clients' rights to autonomy makes me a much better clinician. It means I have explain treatment options in ways that are comprehensible (which means I need to fully understand those treatment options), and it means I need to develop a plan with my client that we can both buy into, which means I need to treat my client with enough respect that they will be willing to develop a plan with me in the first place.

It's total confirmation bias, but I have found that the clinicians I know who work exclusively in involuntary settings tend to bulldoze clients (because they can) and therefore end up with much worse treatment outcomes (because clients are understandably reacting to having their autonomy taken away; a lot of times when you treat other people like children, they react by lashing out like children).

There are times when I do need to put clients on involuntary holds for their own (or others') safety, and it can be frustrating when a client is obviously impaired but does not meet legal criteria for a hold, because at that point the client is unlikely to be together enough to work with the me or my co-workers (at least in my setting, where we're dealing with a lot of mania and psychosis) but we can all see that things are likely to end badly, and it's so tempting to want to bend the legal definitions a bit. But I think making it easier to force clients into treatment would give us too much power, which might help in the immediate short-term but would absolutely erode the treatment alliance, and therefore treatment outcomes, in the long-term. Forcing treating professionals to treat people with mental illnesses as people, rather than as recalcitrant children, is an important safeguard in keeping our profession from abusing our power.

And I definitely echo other people's points that there are so few treatment options, voluntary or not, right now, and these bills and proposals never seem accompanied by money to expand the programs they intend to flood with clients.
posted by jaguar at 7:14 PM on December 10, 2015 [9 favorites]


But I think making it easier to force clients into treatment would give us too much power, which might help in the immediate short-term but would absolutely erode the treatment alliance, and therefore treatment outcomes, in the long-term.

Oh man can you please please please please write an editorial for somewhere about this.
posted by listen, lady at 5:51 AM on December 13, 2015 [2 favorites]


Oh man can you please please please please write an editorial for somewhere about this.

I would love to, but my job situation won't really allow it. It is a commonly-shared belief among my co-workers, though, so I swear that many of us do understand that!
posted by jaguar at 9:21 AM on December 13, 2015


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