6 ms·

> 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

by mabbo 10y 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 10y 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.
- got2surf 10y ago
  True, but in the article, both Partovi and Ruffin cite examples of clients who "claim they own a house, or that a relative will show up any day now", despite being injured/homeless/exposed. To me at least, it seems logical that a reasonable person would choose shelter over being outdoors and injured for 15 years. Making that choice is their right, but let's address their mental health problems first to give them the autonomy to make that choice.
  - csours 10y ago
    Mentally healthy people lie to themselves all the time too. Homeless mentally ill people be lying to save face, or that me be at least a component of what they are saying. If you spend enough time with them, you may get a lucid moment where they can be honest with themselves and you; but it is very time consuming to get there.
  - galdosdi 10y ago
    Yes, but you and the grandparent commenter seem to treat it as black and white -- either they are sane, or ALL logic has gone out the window. Many (most?) actual mentally ill are not like that (spoken from first and secondhand experience) -- SOME logic has gone out the window, and there is room to "negotiate" or "convince" in alternate ways. But that requires getting to know them, caring, spending enough time to earn some trust and understand more what kind of entreaty would most appeal to them. A good comparison is a young child (or an elderly person slowly getting senile)! They often believe silly things, but it's not all or nothing. It's possible to "reason" with them, but it takes more effort, time, and care, that's all.
    - deleted 10y ago
      [deleted]
- mabbo 10y ago
  You're 100% correct. I've edited my comment to add the caveat that I should have originally added- I'm talking about the extreme cases here. 99% of people with milder forms of mental illness do need to be treated with respect of autonomy. It's the last 1% that worry me.
  - mercer 10y ago
    I'd argue that our approach should be similar to how we (should) approach people in general: innocent until proven guilty. In my opinion it's preferable to have the occasional mentally ill person do something terrible if it keeps us from having a mentally ill person deprived of their freedom and autonomy without it being necessary.
- watwut 10y ago
  Well, psychology and psychiatry are sad mostly hopeless professions :).
  - Nomentatus 10y ago
    To my surprise, not according to the frontline psychiatrists I've been able to ask personally, who took the worst cases over decades (they were government employed and never saw a paying customer.) It's not just that we do have some effective medications, it's also that people with mental illnesses (other than age-related dementia of course) tend to improve markedly as they age, especially over age 50. Admittedly, that discussion was a couple decades ago, however.
theWatcher37 10y 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 10y 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.
- EGreg 10y ago
  He doesn't need to generalize about all of it to assert that there are some cases like this. What do you do with those?
  - jdbernard 10y ago
    I would even go as far to suppose that most of the cases of persistent homelessness are cases like this. Many of the less extreme cases are being successfully treated to some degree. I'm speaking as someone with personal experience, as I have several friends at different points along this spectrum.
    - pmiller2 10y ago
      Many are not, as well. There are places in the US where, unless one is a veteran, addict, or actively and imminently suicidal, there are no free or sliding scale mental health services available. None! In a very small town, there might not even be a shelter available. It also takes a certain degree of sophistication to be able to navigate the various bureaucracies providing what services there are. Even getting to appointments is difficult when there is little public transportation.
narag 10y ago
Actually I'd say that people being wrong about their own safety and well being is the rule, not the exception.
sgift 10y 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 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."
- deleted 10y ago
  [deleted]
surfmike 10y 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_psychiatric_hold) 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.
- humanrebar 10y ago
  There are parallels here to healthcare-by-emergency-room versus actually having healthy people. It's obvious that we should commit people who wave around guns and think there are Martians in their teeth. But there are also homeless people who just get agitated, verbally abusive, and mildly violent on a semi-regular but certainly dysfunctional basis. How do we help them, and barring that, how do we protect others, including other people who live in the same shelters?
  - surfmike 10y ago
    Yes, I'd say having more social workers on the streets and shelters following up and offering care options for those who are mentally ill and dysfunctional would help the problem. But there's not really funding for that.
    - mercer 10y ago
      I've heard a lot of stories from friends of mine who work in the field, and the picture they paint is that a big problem is bureaucracy/'managerial class'. It's a very similar and equally ugly picture that is painted by the friends I have in academia. What I find interesting (and tragic) is that it doesn't seem to primarily be about funding, but rather about the system that has grown around them, full of inefficiencies and 'false' measurement-based methodology.
sixstringtheory 10y 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-ikkyu 10y 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.

by mabbo 10y ago

dangerlibrary 10y 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.

got2surf 10y ago
True, but in the article, both Partovi and Ruffin cite examples of clients who "claim they own a house, or that a relative will show up any day now", despite being injured/homeless/exposed. To me at least, it seems logical that a reasonable person would choose shelter over being outdoors and injured for 15 years. Making that choice is their right, but let's address their mental health problems first to give them the autonomy to make that choice.
- csours 10y ago
  Mentally healthy people lie to themselves all the time too. Homeless mentally ill people be lying to save face, or that me be at least a component of what they are saying. If you spend enough time with them, you may get a lucid moment where they can be honest with themselves and you; but it is very time consuming to get there.
- galdosdi 10y ago
  Yes, but you and the grandparent commenter seem to treat it as black and white -- either they are sane, or ALL logic has gone out the window. Many (most?) actual mentally ill are not like that (spoken from first and secondhand experience) -- SOME logic has gone out the window, and there is room to "negotiate" or "convince" in alternate ways. But that requires getting to know them, caring, spending enough time to earn some trust and understand more what kind of entreaty would most appeal to them. A good comparison is a young child (or an elderly person slowly getting senile)! They often believe silly things, but it's not all or nothing. It's possible to "reason" with them, but it takes more effort, time, and care, that's all.
  - deleted 10y ago
    [deleted]
mabbo 10y ago
You're 100% correct. I've edited my comment to add the caveat that I should have originally added- I'm talking about the extreme cases here. 99% of people with milder forms of mental illness do need to be treated with respect of autonomy. It's the last 1% that worry me.
- mercer 10y ago
  I'd argue that our approach should be similar to how we (should) approach people in general: innocent until proven guilty. In my opinion it's preferable to have the occasional mentally ill person do something terrible if it keeps us from having a mentally ill person deprived of their freedom and autonomy without it being necessary.
watwut 10y ago
Well, psychology and psychiatry are sad mostly hopeless professions :).
- Nomentatus 10y ago
  To my surprise, not according to the frontline psychiatrists I've been able to ask personally, who took the worst cases over decades (they were government employed and never saw a paying customer.) It's not just that we do have some effective medications, it's also that people with mental illnesses (other than age-related dementia of course) tend to improve markedly as they age, especially over age 50. Admittedly, that discussion was a couple decades ago, however.

theWatcher37 10y 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 10y 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.

EGreg 10y ago
He doesn't need to generalize about all of it to assert that there are some cases like this. What do you do with those?
- jdbernard 10y ago
  I would even go as far to suppose that most of the cases of persistent homelessness are cases like this. Many of the less extreme cases are being successfully treated to some degree. I'm speaking as someone with personal experience, as I have several friends at different points along this spectrum.
  - pmiller2 10y ago
    Many are not, as well. There are places in the US where, unless one is a veteran, addict, or actively and imminently suicidal, there are no free or sliding scale mental health services available. None! In a very small town, there might not even be a shelter available. It also takes a certain degree of sophistication to be able to navigate the various bureaucracies providing what services there are. Even getting to appointments is difficult when there is little public transportation.

narag 10y ago

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

sgift 10y 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 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."

deleted 10y ago
[deleted]

surfmike 10y 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_psychiatric_hold) 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.

humanrebar 10y ago
There are parallels here to healthcare-by-emergency-room versus actually having healthy people. It's obvious that we should commit people who wave around guns and think there are Martians in their teeth. But there are also homeless people who just get agitated, verbally abusive, and mildly violent on a semi-regular but certainly dysfunctional basis. How do we help them, and barring that, how do we protect others, including other people who live in the same shelters?
- surfmike 10y ago
  Yes, I'd say having more social workers on the streets and shelters following up and offering care options for those who are mentally ill and dysfunctional would help the problem. But there's not really funding for that.
  - mercer 10y ago
    I've heard a lot of stories from friends of mine who work in the field, and the picture they paint is that a big problem is bureaucracy/'managerial class'. It's a very similar and equally ugly picture that is painted by the friends I have in academia. What I find interesting (and tragic) is that it doesn't seem to primarily be about funding, but rather about the system that has grown around them, full of inefficiencies and 'false' measurement-based methodology.

sixstringtheory 10y 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-ikkyu 10y 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.