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I’m a psychiatrist, and I worked at Oregon State Hospital. This article, like most articles about mental health, raises some important issues while somehow man

I’m a psychiatrist, and I worked at Oregon State Hospital. This article, like most articles about mental health, raises some important issues while somehow managing to get lots of things wrong. First off, the remodeling of Oregon State Hosital resulted in a net decrease in beds. Another recent project to consolidate most of the inpatient psychiatric beds in the center of Portland also resulted in fewer beds, but let local hospitals divest themselves of inpatient units they never wanted because they lose money. So, there are not many places for people with active and severe mental illness to get inpatient treatment (which is, of course, not the only way to get treatment, but can be a major one for people who are incapable of recognizing they are ill). Having worked in other states, it is my opinion that the crux of the problem is that there are too few avenues to get people help when they need it but don’t recognize the need. Because it’s so increadibly hard to get people involuntarily hospitalized (which I recognize can be abused), we end up with them being arrested instead. As noted above, involuntary hospitalization can be abused, but when so many mentally ill people go untreated until they are arrested it’s perhaps time to reconsider if things are working as intended. Then, once someone is arrested, evaluated as needing to be restored to competency for trial, and finally gets to the hospital, many of them decline medication. For most of them, it’s implausible that their condition will improve without it. So they have arrived at a point in their life where they don’t know they are ill, have done something to get themselves arrested that’s often related to their symptoms, and continue to decline treatment. I see it as an unintended consequence of such strong protections on individual rights. Of course those individual rights should be protected, but I would respectfully suggest it’s time to reconsider where the lines are drawn. This movement of the mentally ill from asylums (where they were often mistreated) to jails and prisons has been dubbed “trans-institutionalization” if you want to read more about it.

ColanR 8y ago
It is a Big Deal to deny someone their autonomy, no matter which way you slice it. I think we agree on that. But, respectfully, I think that because it is such a big deal, imprisonment is the proper escalation. It's necessary to maintain a sense of proportion, and we need to avoid - at all costs (and I think that is where we diverge) - the decrement of the right to autonomy. If we make it less of a Big Deal to revoke that right, 'merely' hospitalizing them, we lose our respect for that autonomy.
- phren0logy 8y ago
  That’s the tact that Oregon has taken, and I can see the logic in it. But as a doctor I find it more palletable to explicitly try to work in someone’s best interest than to send them to jail/prison. I am obviously biased, but I have seen hundreds of people get well and go on to live lives that they themselves would identify as more rewarding. Deprivation is, and should continue to be a very big deal. But when it becomes necessary, I’d rather that it be focused on the best interest of a person who’s not in a position to recognize their own circumstances. Clearly it’s a value judgement and there’s no one right answer. It depends on which of two bad options you find least offensive.
  - hirundo 8y ago
    > Psychiatry possesses an inherent capacity for abuse that is greater than in other areas of medicine. The diagnosis of mental disease can give the state license to detain persons against their will and insist upon therapy both in the interest of the detainee and in the broader interests of society. In addition, receiving a psychiatric diagnosis can in itself be regarded as oppressive. In a monolithic state, psychiatry can be used to bypass standard legal procedures for establishing guilt or innocence and allow political incarceration without the ordinary odium attaching to such political trials. https://en.wikipedia.org/wiki/Political_abuse_of_psychiatry_in_the_Soviet_Union https://en.wikipedia.org/wiki/Political_abuse_of_psychiatry_... Is that "inherent capacity for abuse" overstated? I'm less afraid of the corrupt psychiatrist than of the one sincerely convinced that people who think like I do are sick.
    - phren0logy 8y ago
      It is real and relevant, and already accounted for in the concerts about limiting personal liberty. The usual mechanism to address this is to require more than one clinically trained person to agree, which holds them for a few days until it can be heard in court and decided by a judge. This requires it only illness but immediate danger to self or others. This has had the unintended consequence of conflating mental illness with violence. Always trade offs...
deleted 8y ago
[deleted]
droithomme 8y ago
> there are too few avenues to get people help when they need it but don’t recognize the need Do you mean forced treatment aka involuntary hospitalization? What are the statistics on cure for this? Does treatment work? If cure rates are not high, is this just long term incarceration without due process that finds one has actually committed a crime?
joveian 8y ago
There was also an article recently about how the state kicked a bunch of people out of residential facilities: https://www.oregonlive.com/health/index.ssf/2018/11/moving_oregonians_with_mental_illness_out_of_locked_facilities_was_the_goal_but_things_didnt_go_as_planned.html https://www.oregonlive.com/health/index.ssf/2018/11/moving_o... It seems like everyone agrees that community services are hugely underfunded. Given that situation, I find it hard to believe that lack of involuntary commitment is much of an issue. How would involuntary commitment help if resources aren't available for voluntary treatment? I also think you are underestimating the abuses of involuntary commitment. Unity was almost shut down due to various issues. Attempted treatments can also cause lifelong issues and there seems to often not be effective treatment available. The main reason I posted this article is that I wasn't aware of the situation where people who are judged incapable of assisting in their own defense are being given the maximum possible punishment for the category of crime they are accused seemingly without any attempt at considering if that is reasonable without their involvement.

ColanR 8y ago

It is a Big Deal to deny someone their autonomy, no matter which way you slice it. I think we agree on that. But, respectfully, I think that because it is such a big deal, imprisonment is the proper escalation. It's necessary to maintain a sense of proportion, and we need to avoid - at all costs (and I think that is where we diverge) - the decrement of the right to autonomy. If we make it less of a Big Deal to revoke that right, 'merely' hospitalizing them, we lose our respect for that autonomy.

phren0logy 8y ago
That’s the tact that Oregon has taken, and I can see the logic in it. But as a doctor I find it more palletable to explicitly try to work in someone’s best interest than to send them to jail/prison. I am obviously biased, but I have seen hundreds of people get well and go on to live lives that they themselves would identify as more rewarding. Deprivation is, and should continue to be a very big deal. But when it becomes necessary, I’d rather that it be focused on the best interest of a person who’s not in a position to recognize their own circumstances. Clearly it’s a value judgement and there’s no one right answer. It depends on which of two bad options you find least offensive.
- hirundo 8y ago
  > Psychiatry possesses an inherent capacity for abuse that is greater than in other areas of medicine. The diagnosis of mental disease can give the state license to detain persons against their will and insist upon therapy both in the interest of the detainee and in the broader interests of society. In addition, receiving a psychiatric diagnosis can in itself be regarded as oppressive. In a monolithic state, psychiatry can be used to bypass standard legal procedures for establishing guilt or innocence and allow political incarceration without the ordinary odium attaching to such political trials. https://en.wikipedia.org/wiki/Political_abuse_of_psychiatry_in_the_Soviet_Union https://en.wikipedia.org/wiki/Political_abuse_of_psychiatry_... Is that "inherent capacity for abuse" overstated? I'm less afraid of the corrupt psychiatrist than of the one sincerely convinced that people who think like I do are sick.
  - phren0logy 8y ago
    It is real and relevant, and already accounted for in the concerts about limiting personal liberty. The usual mechanism to address this is to require more than one clinically trained person to agree, which holds them for a few days until it can be heard in court and decided by a judge. This requires it only illness but immediate danger to self or others. This has had the unintended consequence of conflating mental illness with violence. Always trade offs...

deleted 8y ago

[deleted]

droithomme 8y ago

> there are too few avenues to get people help when they need it but don’t recognize the need Do you mean forced treatment aka involuntary hospitalization? What are the statistics on cure for this? Does treatment work? If cure rates are not high, is this just long term incarceration without due process that finds one has actually committed a crime?

joveian 8y ago

There was also an article recently about how the state kicked a bunch of people out of residential facilities: https://www.oregonlive.com/health/index.ssf/2018/11/moving_oregonians_with_mental_illness_out_of_locked_facilities_was_the_goal_but_things_didnt_go_as_planned.html https://www.oregonlive.com/health/index.ssf/2018/11/moving_o... It seems like everyone agrees that community services are hugely underfunded. Given that situation, I find it hard to believe that lack of involuntary commitment is much of an issue. How would involuntary commitment help if resources aren't available for voluntary treatment? I also think you are underestimating the abuses of involuntary commitment. Unity was almost shut down due to various issues. Attempted treatments can also cause lifelong issues and there seems to often not be effective treatment available. The main reason I posted this article is that I wasn't aware of the situation where people who are judged incapable of assisting in their own defense are being given the maximum possible punishment for the category of crime they are accused seemingly without any attempt at considering if that is reasonable without their involvement.