Medicating a Prophet | Hacker News Reader

Medicating a Prophet

nytimes.com

78 pointssantaclaus49 comments

Fascinating article. Who decides the mission of a psychologist? Is it to maximize happiness of patients' lives as a whole? Is it to help patients to reach their full potential as productive members of society? Is it to help them to conform to societal standards of behavior or belief?

If I wasn't on guard, prepared to devote thought to the question, I'd have accepted any of those answers - but this article makes it easy to see how those different goals can be in conflict.

If I had to come up with the best answer I could, I think I'd settle on "A psychologist's mission should be to prevent a person from actively harming the physical health of themselves or others, even taking into account reasonable expectations of future harm based on current activities. And additionally to help make any adjustments that the patient requests." So, sometimes it's okay to involuntarily treat, but only if there's a present or soon-to-be present physical danger. Otherwise, only help them with the things they want fixed.

(Note: I once had a long and coherent conversation with a guy who knew he was the messiah promised to the jews, descendant of david, future king of the world. It was an unavoidable fact. Him being a young, black presbyterian had no bearing on the issue. He had lots of evidence, much of it delusional, and much of his reasoning was based on bad information that he was literally incapable of doubting. But in the end, his delusion was immensely satisfying to him, and his life was otherwise boring, banal, and from an outside perspective, depressing as hell. And from what I can tell, as long as he doesn't travel to Israel and get a jewish girlfriend, the more dangerously bizarre parts of his prophecies won't begin, so I just decided to wish him well and let it go.)

> So, sometimes it's okay to involuntarily treat, but only if there's a present or soon-to-be present physical danger

If you weren't aware, that is the current standard for involuntary hospitalization, at least in the US. I believe the phrase is "danger to self or others."

Florida's involuntary commitment criteria are probably the loosest in the US[1]:

    CRITERIA.—A person may be taken to a receiving facility for involuntary
      examination if there is reason to believe that the person has a mental
      illness and because of his or her mental illness:
      (a) 1. The person has refused voluntary examination after conscientious
             explanation and disclosure of the purpose of the examination; or
          2. The person is unable to determine for himself or herself whether
             examination is necessary; and
      (b) 1. Without care or treatment, the person is likely to suffer from
             neglect or refuse to care for himself or herself; such neglect or
             refusal poses a real and present threat of substantial harm to his
             or her well-being; and it is not apparent that such harm may be
             avoided through the help of willing family members or friends or
             the provision of other services; or
          2. There is a substantial likelihood that without care or treatment
             the person will cause serious bodily harm to himself or herself or
             others in the near future, as evidenced by recent behavior.

Note that this is only supposed to result in a 72-hour evaluation. It has also been fraught with allegations of abuse by family members, schools, and courts who don't want to properly deal with complex psychological and behavioral issues in more appropriate ways.

[1] Full Baker Act is here: http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Displ... The criteria are specifically from 394.463 (1).

It's interesting that Florida's solution is still fraught with abuse because those conditions are about the broadest I'd consider reasonable when removing a person's autonomy.

Sadly, being on the streets and incapable of caring for oneself isn't considered a 'danger to self', at least in the eyes of the hospital that evaluated my former fiancee.

Personally, I think we need to set the bar for involuntary intervention higher than being an active threat. If someone doesn't have the mental wherewithal to not lose their coat in the middle of a cold snap, that seems like a clear indicator to me that they need help and their refusal shouldn't be taken any more seriously than their delusions.

I may be biased and embittered on this subject.

To me, freezing yourself to death seems like a case of 'danger to self' but I'm neither a lawyer nor a doctor.

But in other situations, the question arises just like in the article. At what point do you want to dose the individual with a sense of reality? If their mentally-ill self is content with the life they lead and "curing" them of it will leave them empty, sad, and hollow (in addition to the side effects of medication), is the arguably a better option?

If you factor in the fact that the hospital won't be there to help him rehab back into society, I can see the decision being difficult to make, as the author mentions.

I mean, it could be interpreted as a 'danger to self', but choosing that interpretation loses the hospital money. I'm saddened but not really surprised.

That may be the official standard, but in reality the evaluating psychiatrist commits you if he wants to, and they do sometimes err on the side of caution. So it's somewhat arbitrary depending on where you are and when.

Just a question, but how strictly is that followed? If a mentally disturbed person (who presents no current physical threat) is put in front of a psychiatric professional, how often is that professional going to say "Ah, let him/her be. They aren't going to harm anyone". Especially in today's climate of preemptive responses to threats.

As someone who went to Virginia Tech I've seen how that "eh, he's/she's not bothering anyone" response can go terribly wrong. And when it goes wrong, the first thing people will ask is why that professional didn't do something when they had the chance.

One thing that wasn't addressed in the original article is that there's not a lot of room in psychiatric hospitals and not a lot of funding to keep people there long-term. So that results in a more or less tacit revolving door policy, and certainly affects the decision to involuntarily commit or not.

Generally, professionals will not involuntarily commit patients unless the threat is current and pretty explicit, though there are exceptions. Professionals can involuntarily commit people for short periods of time for observation, to determine if they really are or are not a risk. For instance, if someone shows up in the ER with knife wounds on their wrists, that can warrant an observation period. Interactions with the police can lead to observation if the officer believes you to be mentally ill.

It's a very fine line to walk between individual liberties and providing treatment to those who need it. If you're schizophrenic and you live on the streets, yell at birds all day, and eat from the garbage, you are not considered a danger to yourself, even though you have a pretty abysmal quality of life and are at serious risk of dying from disease, drugs, homicide, exposure, or starvation. It's a complicated conversation with no clear answers.

I am fascinated as to why psychosis so often takes such a religious bend.

Purely speculatively, I would guess that is doesn't, naturally. But religious indoctrination is extremely common. So, it makes sense that if any given person is experiencing a mental break that there's a reasonably high chance they will have a religious background rife with grand concepts to pull from.

The one person I knew personally who broke with reality wasn't religious, and instead seemed to be pulling ideas from her previous goals and highlights of her life. She described a sort of ideal version of her life, the best things she could think of in the moment, regardless of consistency or reality. It makes sense that if one were raised in a religious household, one would talk about being chosen by God or some such instead of how you were getting straight A's in school and getting hired by 5 different places.

Cultures experience mental illness in very very different ways.

http://news.stanford.edu/2014/07/16/voices-culture-luhrmann-...

People tend to think their talking to spiritual things in some sense, but Americans heard God, or angels or demons, Indians tended to hear from ancestors or kin, Ghanaians from various spirits. Indians and Ghanaian found that many voices where helpful and positive. The Americans all found their voices to be violent and negative.

One prophet whom I will not name here initially believed to be possessed by the evil spirits but his wife, which had the monotheistic upbringing, made him believe it was an angel of the God. There's a touching scene where she makes him sit on her one and then another leg, and then she makes him sit on her lap and undresses. As the "images" he saw disappeared at that moment she "proved" him that it's not an evil but the "holy" power that possesses him.

She probably just wanted to calm him down and make him see the world more positive. Eventually it wasn't positive for his opponents and the world. He started to believe he has the direct connection with the God and that therefore anything he does, even the killings and tortures, were directly supported by the God. He turned out to be a "successful" prophet based on the impact he made.

I am by no means a religious expert but it's sad that your very reluctance to name the prophet in question made him easy to guess. And it led me down a bit of a rabbit hole:

https://wikiislam.net/wiki/Muhammad%27s_Just_In_Time_Revelat...

And on and on:

http://quotingislam.blogspot.co.at/2011/06/muhammad-orders-t...

It's worth considering that there are differing opinions on what constitutes danger.

Some would consider religious indoctrination dangerous. Few would agree on the definition of indoctrination.

I once encountered a young man who was reading the Necronomicon, a cheap and utterly fictional paperback put out to tie-in with the Lovecraft mythos. It's a prop to make a few bucks, no more real than a plastic Star Trek phaser.

Something about the way he was reading it caught my attention, so I asked him, "You know that's fake, right?" To my astonishment, he began to protest and describe how "they dug it up in an archeological site" or something. The chilling thing was he really seemed into it.

I left thinking, "There's the formation of a psychotic reality, right there in front of me." Dunno what I could have done about it.

How's this any different from people who spend tens of thousands of dollars stocking up on food and weapons because they're convinced we're on the brink of nuclear war, or people who are convinced that Obama is a secret Muslim terrorist infiltrating America, or people who absolutely believe that the (Bible/Qu'ran/Old Testament/...) is the word of god, or...

> spend tens of thousands of dollars stocking up on food and weapons because they're convinced we're on the brink of nuclear war

I mean, I haven't stockpiled anything personally, but honestly that's a pretty reasonable cost-benefit analysis. The world _is_ perpetually pretty close to nuclear war, if you treated the risk like any other day to day risk.

(You probably spend more on health and house insurance than they spend on food, and IMO nuclear war is more likely than a given house catching fire in a year. The unknowable question of course is whether it will manifest in a way that your preparations matter)

Well, I don't know what all is in the paperback Necronomicon, because I'm a science fiction fan, not a Cthulhu Mythos camp follower. But if it's at all in accord with the depiction of cultists in Mythos fiction, I can see an argument that someone who genuinely buys into it, to a degree consistent with psychosis, might be more dangerous than someone who buys into something else to a similar degree.

It seems very probable that the cited book is the "Simon Necronomicon" [1], which appears to incorporate a lot of Derleth's rather disappointing Manichaeism. I'm not sure whether, in this context, that would make it more dangerous or less so, or indeed whether it would make any significant difference at all. I'd be curious to discuss the matter with someone like the person mentioned by the grandparent commenter. But I would very much prefer to do so in a context where I could be very certain he hadn't decided to follow me home.

[1] https://en.wikipedia.org/wiki/Simon_Necronomicon

I feel it's kind of different. Frankly, not freaking out over nuclear seems to be crazy thinking - even though it's also required to live a normal, sane life. I wonder how many things people shut off in their lives this way in order to cope.

That's exactly my point: Some horseshit written by some nameless hack to make a few bucks and here's this kid founding his reality on it. Yikes!

At least nuclear bombs are real. It makes a little more sense to worry about them than Cthuloo.

Maybe nothing other than scale and consequence.

> That night 13 years ago, I did hospitalize my patient who thought he was a prophet, and he received treatment that he had not consented to. I never found out what happened to him. I think about him often; I question my decision each time I do.

Regardless of whether she was right to commit the person to treatment -- how did she not follow up on this? That shouldn't be the end of the article. Why didn't she follow up? If she thinks about it she was obviously interested on some level. Was she legally prevented from following up? Shouldn't follow up be required?

You expect a resident called into an ER in the middle of the night to follow up on the long-term treatment of every patient?

I'm often bummed out whenever someone tells me about their problems and I talk to them about solutions or new ways of thinking and they tell me they just want an ear to speak to.

If I weren't empathic I could just shrug but I see people making big life choices over ridiculous assumptions and I'm asked to keep my expert advice to myself.

This article shakes me at my core... perhaps what's best is to be there until things blow up and then swoop in and save the people from an even worse spot.

Sometimes people need to their own processing in order to own their solutions. You just need to rubber duck them through it... Advice then is better given by asking questions than by providing answers.

As I've grown older, I've learned that often the best thing is to just listen to people. Sometimes just letting people vent and share their problems is the most you can do (and it is helpful to most people to have an outlet, even if to you it seems like you're not "doing anything" or "solving the problem").

Agreed. And if they're looking for help, they'll usually ask for it.

"What's your opinion?"

"What would you do?"

I agree, though not everyone does this—it depends on the person and the interaction a lot I think. If I can't tell, I usually just like to ask:

"What do you think you'll do?"

This is often helpful and I sometimes consider it as a listening strategy.

Are you sure you're not the same when you tell someone your problems? How do you react when they give you advice that is outside of your own mental model, or that is different from what you want to hear?

I'm sure sometimes your assessment that someone else's assumptions are "ridiculous" is fair, but will you consider that sometimes it is your assumptions about their assumptions that are limited or flawed?

From the article:

> If, however, lack of insight is defined as a failure to accept an alternative view of reality, then do the rest of us lack insight, too?

> The assumption that someone else’s reality is invalid can foster distrust; it sends the message that we don’t respect this person’s experience of his or her own life. Many people who have been in the mental health system describe themselves as “survivors” — not of mental illness, but of treatment.

I've found it best to be a good listener and only offer advice when it's explicitly asked for -- otherwise, simply offer attention or sympathy/empathy.

I don't often go to other people with my problems. I tend to work through the lot of them on my own. I think many people are this way, and really only go to others to not feel crazy for having a certain issue. (i.e. finding someone who can relate to their struggles, not necessarily solve them)

There was and is an anti-psychiatry movement[1] which has a very interesting history.

[1] - https://en.wikipedia.org/wiki/Anti-psychiatry

Psychiatry is the only medical specialty to have an active resistance movement. The problem is that their go-to treatments are palliative, and do NOT address any of the causes of their patients' conditions.

Robert Whitaker has found the evidence supporting the use of commonly-used drugs actually shows that psych patients do very poorly when medicated for an extended period of time [1].

[1] http://www.madinamerica.com/2016/07/the-case-against-antipsy...

Before the tranquilizers became available, people had episodes from which they usually recovered. Now their chronic conditions are 'managed', until they die 20 years earlier than would otherwise be expected.

I read the article and can't help but wonder where the family is in these situations. Why are doctors forced to commit someone against their will? Isn't that a decision better left to a family member?

More and more we're asking society to take on the role traditionally held by family members. The author is describing a symptom to a greater issue, which itself is probably a symptom to some other issue as well. It's symptoms all the way down.

Not to attack you, but that's a little closed minded.

Not everyone has a family structure to depend on. Many times, that's a contributing factor to the predicament that disturbed person is in.

We're usually there, but helpless. When you watch somebody slipping, even into dangerous territory, you're left with a limited set of options. Unless the family can prove "Imminent Danger to Self and others" or the person in question consents to treatment, we're just as helpless as the doctor here, even in concert with the person's care provider. So, much like the recent Michigan "poisoning" case (http://www.mlive.com/news/ann-arbor/index.ssf/2016/07/man_ac...), you just have to watch until the person crosses a line where they can be legally held. And often, that's after somebody's hurt.

I suspect that in many of these situations, particularly where a person has lost touch with reality, but not quite at the "I am the angel of death" level, the family is in the background and well aware, but simply out of legal options to help.

Thanks for reminding me that I need to do explicit legal documentation that my parents should have nothing to do with my medical or psychiatric care, ever.

Some roles should not be held by some people, tradition be damned.

Another big problem is that if a hospital admits a patient for mental issues, they'll have to treat their physical ailments as well. Since the patients does not have any money or insurance, that comes out of the hospitals pocket. So they have an incentive to cut as many "harmless" people loose as possible.

Every single person who advocates or speaks in a visionary way about a new belief, cause, or theory is a prophet. Silicon Valley is full of prophets trying to profit from making their internal view an external view for all of us.

I guess I would call those SV people inventors and/or entrepreneurs? Or visionaries (in the business school sense or the literary sense, not in the mystical sense)? There are multiple definitions of the word "prophet" and you have chosen the one where someone just imagines something that doesn't currently exist, but might or will someday. i.e., a prophet is just someone who is prophetic in the broadest possible sense of the term.

I think of a prophet (in the context of this article and this thread) as someone who is convinced that they literally have supernatural insight gifted to them by some unseen omnipotent being who sits behind the curtain of the universe pulling the levers.

I'm not inherently scared of someone who thinks that if only they could get the right product out there, they could make some money (and maybe even make some people happier in ways that they weren't before). I am inherently scared of someone who has convinced themselves that some unseen omnipotent being has a message for the world about who's good and who's evil and what's going to happen in the future, and everyone who doesn't get on board deserves to have bad stuff happen to them (in this life or the next).

Although, I guess that person is harmless in isolation- what I'm really scared of are the people who hear someone like that and decide, "hey this guy clearly knows what's up, let's just listen to (and do) whatever he has to say, and stop thinking about all these hard questions about ethics and morality and life and justice. Even better, we get to act like we know infinitely more than all those poor bastards who wrestle with that stuff every day!". Anyway, that's what I think of when I think of a prophet. Someone who claims to have the answers to the hard questions via magic.

Two much more powerful, deeper, and more interesting articles on the same subject:

http://www.newyorker.com/magazine/2011/05/30/god-knows-where...

http://www.columbia.edu/cu/neuwrite/pubs/avivHarpers.pdf

I have said more than once that if Joan of Arc were alive today, she would be in a psych ward having hervmedsxadjusted instead of ending The Hubdred Years War and playing handmaiden to the birth of modern France.

I am glad this article is promoting the idea that forcibly treating someone is not really a means to foster mental health. Good mental health is more than the absence of obvious abnormality.

>He was a college graduate from a middle-class family. But on Christmas Eve three decades earlier, the Archangel Michael had come to him in a vision and demanded that he spread God’s word.

Suppose it's false.

Given that it's false, are his actions acceptable conduct for a person? Really what is unacceptable is going without treatment for obvious full-blown AIDS.

>I run a program for young people experiencing psychosis for the first time. Every day I confront my impulse to coerce people into care. This spring, one of our participants, whom I will call Mark, once again went off his medications. He had been on track to finish his first semester of community college and was looking for part-time work when his father showed up after years of absence. Soon he was smoking weed daily with his father, had dropped out of school and was refusing to take his medications. Over the next few months he became increasingly psychotic, stopped sleeping and started rhyming all his sentences. Then the sentences gave way to incoherent word pairings that psychiatrists call “clanging.” Soon he was nearly mute and rail-thin. But he still refused medication.

You're lying.

Not to me, and not to Mike, but to yourself and to society. Nobody wants to help Mike be himself or be happy. That's Mike's job. The modern paradigm of psychiatry says "take your medications so that you can be happy", but what we obviously mean is "take your medications so that you can work". Here's the thing: he'll be just as happy smoking weed and babbling as he is at college. Or, to be more honest, we have no good evidence that he won't be.

Here's the thing: how on Earth is Mark supposed to work if nobody cares that he does? The society around him has stated quite clearly that it isn't worth going to a bunch of effort to get him to work -- he's not being medicated in order for him to work -- his work isn't necessary or a duty, according to everyone who tells him anything about anything -- yet the actual standard being applied is "does this guy pass his classes?".

The truth is that that sounds awful. But the deeper truth is that the psychiatrist and the family and the legal system as a whole have collectively chosen the non-awful fantasy of "mental health" rather than the awful reality of "crazy people are useless". And then we wonder why the patient wants to make the same kind of choice!

> Here's the thing: he'll be just as happy smoking weed and babbling as he is at college. Or, to be more honest, we have no good evidence that he won't be.

You stopped reading at the smoking weed part. After that, he stopped eating, sleeping, and talking. What part of that sounds happy or healthy to you?

It doesn't really matter.

I mean, sure, it might affect the way this example can be used to make the point, but, in my experience, the thrust of my argument holds in plenty of situations anyway. And I'm not sure I agree anyway: happy is a very subjective judgment.

The only difference between a prophet and a madman is the number of followers they have.

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