What to do with mentally ill homeless people who refuse help?
latimes.com
latimes.com
http://graceofgodmovie.blogspot.com/2012/01/i-am-super-danny...
It's worth watching all the way through because Daniel undergoes a remarkable transformation over the course of four minutes, simply because I stopped being afraid of him and started treating him with basic respect and decency. It's one of the most important lessons I have ever learned.
Over the course of the next two years I learned a lot more about mental illness and the often subtle ways it can manifest itself, a lot of which is reflected in the film (which you can get on iTunes and Amazon, links are on the home page: http://graceofgodmovie.com/)
It's a very complicated problem. But involuntary commitment to mental institutions is absolutely not the right answer IMHO.
http://graceofgodmovie.com/superdanny.mp4
I could have sworn I put a copy on YouTube but now I can't find it. I'll try uploading it again.
UPDATE: Try this: https://youtu.be/Ah_UglfATU0
The download did play in Quicktime, so perhaps the browsers are being slightly more picky about the file format?
So what is the right format for web videos nowadays?
Still doesn't make sense to me that it works in some applications and not others.
Mental "patients" (prisoners) are deprived of due process, trial by jury, and are subject to cruel and unusual punishment (forced drugging, solitary confinement) and indefinite imprisonment. This in itself is psychologically damaging and further exacerbates the issue.
If a person hurts someone, they should stand trial but until then they should be allowed their inalienable rights.
1. create a new classification of crime outside of normal criminal law (i.e. thought crime, racial impurity, religious heresy)
2. Streamline subjugation of undesireables by skirting the bureaucratic barriers of criminal law system
3. Profit
(PS: Imprisoning people for smoking pot isn't a good example here because it goes through the normal criminal system. And examples from outside the US are practically useless because so many rights and powers differ between the US and even other close govenments like the UK.)
In the 60's and 70's in the US it was not uncommon for parents to have their children committed to asylums because they were high on marijuana (it was called "reefer madness" after all). And even today recreational use of marijuana is considered a mental illness according the the DSM-5.
>"There ought to be a new standard of care, said Ruffin, and it should include not just temporary involuntary psychiatric and physical treatment, but long-term case management."
This is the crux of it. Admitting people to a psych ward for an involuntary hold is ripe for abuse. You can respect someone's autonomy (even a homeless person with psychiatric problems' autonomy) and, at the same time, help them not freeze to death.
It usually starts with having enough caseworkers with enough bureaucratic leeway to build actual relationships with their clients. I don't think we're anywhere close to that.
When this stuff is made into a process, it becomes robotic and the empathetic, human element of it is taken away from it.
These people need someone to listen and understand, not necessarily someone to shove anti-psychotics and whatever else caretakers are told to do.
I'm not saying drugs don't help, but it's best when trust is established, and one can help the patient see why the drug is necessary at the time.
That has always been my problem when seeking help for my psychological issues. I'll see a GP or a specialist, get a prescription, they may go over the mechanism of action with me if I push them to, but otherwise I'm told to take 2 every day and report back in a month.
I'm a lab rat. Not a patient. See why these people have trouble getting help? They don't feel like patients getting treatment.
aglavine is right, for example in the case of paranoid schizophrenia. I have personally seen someone I am very close to descend into this madness. When they are not lucid it is literally impossible to establish any trust because the fundamental axioms with which they view the world are skewed. You can reason, but all the conclusions are fore-gone and the paranoid mind will only find more and more fantastical explanations to support the delusion. The delusion is the core reality.
Those of you who down-voted, explain how to establish trust in this context?
Once burned, twice shy. Mentally ill people are frequently harmed by the medications that they're told they have to take. Science now knows that these medications are palliative drugs that actually worsen the long-term prognosis for the patients, but these findings haven't made it to the hospitals yet. [1] [2]
[1] https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2...
[2] https://blogs.scientificamerican.com/cross-check/psychiatris...
I witnessed a mental health crisis team do some very good work in convincing my friend to go to the psychiatric hospital. It was unfortunate that the psychiatrists refused to address the cause of her condition [by that point it was nerve damage from neuroleptics], but at least that guy got her off the street.
How do you do this at scale? One of the challenges with poverty and mental illness is that it gets hard to provide comfort, safety, and opportunity when the homeless are afraid and distrustful of each other, and often justifiably so.
The reason there are so many niche shelters (women with kids, youth, LGBTQ, etc.) is that there's some consensus that the general population shelters are not safe. Some of that is just vanilla crime, but a lot of it is a result of a high concentration of the homeless who are mentally ill.
And it's not generally a mystery which people are refusing help, medical treatment, or mentorship. At what point does it stop being "respecting autonomy" and start being "enabling dysfunction and abuse"?
Despite the fact that homelessness writ large is a Societal Issue, social work succeeds or fails two people at a time, and over the course of months and years.
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.
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.
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.
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.
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.
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...
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.
There are many different mental illnesses and certainly not every one of them in every situation makes your brain unable to do its job anymore. Also, many theories around mental illnesses are actually very vague (e.g. for depression: https://en.wikipedia.org/wiki/Depressive_realism) or the problem that it is very hard to get a conclusive diagnosis which mental illness someone actually has. It happens time and time again that different experts will diagnose different mental illnesses for the same person, because there's no simple test which you can administer, so it is mostly subjective and experience based. Not a good base for "hey, let's decide what's best for these people, because they clearly cannot do it for themselves."
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.
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?
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.
Curious what your thoughts are on both assisted and unassisted suicide.
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.
I have a relative that's homeless and mentally ill and there's absolutely nothing you can do to keep them off the streets. Even with a free place to live he gets kicked out for threatening neighbors or screaming gibberish. Has a criminal record of doing crazy stuff so shelters will give him food but will not let him stay there.
I think anyone that's spent a lot of their life trying to help someone with severe mental illness realizes that the only humane way to deal with these people is to put them in a ward or prison. It's honestly much safer for them there, they get reliable food and some medical care. These types of people are a danger to themselves and being in a controlled environment is the best you can hope for.
I'm personally pleased whenever I hear that my relative is back in jail because then I don't have to worry that he's dying on the side of the road.
Since all the bleeding hearts that haven't dealt with someone in this state keep voting to close down mental wards these people are now flooding the streets, terrorizing people, and dying constantly.
If people don't want mental wards, which is by far the best solution, the alternative becomes putting them on some kind of "homeless island" where they can hurt themselves and each-other but at least not the rest of society.
The best way is to put them back into the mental hospitals where it's safe and they can be cared for. I watched as my relative's old parents fought the state like hell for years to get him committed to the last remaining indefinite-stay mental ward in the state. The alternative was certainly death once they're too old to keep searching for him and bringing him back home (he runs away eventually, or occasionally steals the keys and drives).
Some of these homeless people are so mentally unstable it affects their survival instincts. Like they don't think they need a jacket in -20 weather one day because they saw God this morning and he's going to protect them. And getting someone like this to take their medicine reliably? You've gotta be joking.
That's quite the Orwellian double-speak for incarcerating & drugging people against their will.
EDIT: Also, I haven't read the original pamphlet, but not treating chronic mental illness is often cruel to the other members of the community even if it's not cruel to the individual in question.
And, on a more philosophical level, I see kind and generous people grow callouses in their hearts because there's no real way for a normally-equipped private citizen to help these people. It's great for society to have people that will stop, engage with, and help literally anyone. We regularly take people like that and teach them to be jaded and to keep their distance. But their trust and generosity deserves to be protected as well, in my opinion.
I'm aware that it's oversimplifying, but we don't seem to care as much when it's out of sight.
Then again I'm not sure who can be trusted to decide if someone is making decisions based on reality or fantasy.
The only people now who can sometimes talk him down when he's having problems are me and a couple of other family members that did not participate in pushing for involuntary committal.
Part of the reason why I'm struggling with this question is that since about a year it also applies to me, to an extent. My problem is unrelated to homelessness, but it seems clearer and clearer that the solution that works for me (read: makes me happier and more 'functional' than anything else I've tried) could be considered by many people to be 'worse off', and consequently eligible for some degree of intervention, simply because they are not like myself.
There are no easy answers to these questions, but I feel such answers start with compassion and active engagement with and understanding of those whose lives we are 'managing'. Social workers probably qualify, and the managerial class are probably the last to do so.
Mental illnesses are heart breaking and they're a problem that most people don't want to deal with; those with extreme cases often are shunned by society and end up in precarious situations and fall further into the illness, making treatment even more difficult. It's a very bad situation that doesn't have a clean answer. While I understand that there is a very large air of caution around setting a precedent that the Government can just declare someone insane and remove their free will, there also has to be a practical side when said person is very clearly a danger to those around them. The penal system wants nothing to do with such cases, current mental health and homeless support doesn't have enough support or funding to help out enough of the cases.
It's just a really shitty situation to be in.
I know of a public housing complex that took large numbers of homeless people and had a death rate far over 10% per year despite the fact that every resident had a place to be and an income. If you know people aren't mentally well and are climbing tall bridges by themselves, do you wait 'till they fall off and die? In one case from that building, it turned out the answer (from the government) was "yes."
Part of the problem may well be that high death rates are their own reward, for governments.
I know deep down there isn't much that can be done without incarcerating them, but I also know that taking someone's freedom without proper cause is worse than letting them possibly die by their own choice. There's too much potential to abuse power that let's you lock up someone who is, by and large, law-abiding but mentally disturbed. The hair splitting is dangerous.
That being said, in short order I will likely move to a location in SF where I don't have to see this tragedy play out day to day. If I can't help, and I don't like the current solution, at least I can avoid the situation altogether.
I was aghast and assumed he had to be wrong somehow. Fast forward ten years and downtown Seattle is full of homeless people. Fast forward to today and multiple cities are basically overrun with them, when the population of them was tiny just 20 years ago.
I hate feeling old and partisan but my personal experience leads me to believe this is the crazy GOP policies of the 80s coming home to roost. It's certainly the most likely explanation given what I know and doesn't require some of the mental backflips necessary for other explanations.
The notion that someone who said, "Jesus wants me to live on the street," would suddenly find themselves incarcerated and drugged to change their mind is such a terrifying overreach of state power that it boggles the mind.
But, what do we do when that person changes from "Jesus wants me to live on the street" to "Jesus told me to purify people wearing blue?" Or maybe a less extreme version, "I have been commanded to anoint your car by defecating on it." What is our responsibility as a society to those who through no fault of their own become delusional and dysfunctional to the point where they become abusive towards others? What agent should be charged with this responsibility if not the government?
I don't have a good solution myself. I've just seen the damage mental illness can cause, and it usually isn't limited to the person who is ill. I've had the difficult conversation: "I know they're stalking you, and I know they have a CHL, and I know they are no longer in their right mind, but there are no authorities that can actually do anything until after they directly threaten you in a way that you can prove."
Those with a mental illness are in this case unable to help themselves. It controls them. It's the illness that prevents them from getting help. They may refuse medical care but that's the illness talking.
By not committing them to 'involuntary' hospitalization the state is allowing mental illness to slowly kill the suffering homeless population out on the street.
See Alan Turing.
Well, we can start somewhere, right? Like fraudulent panhandling. Or the various forms of low-grade assault that is typically ignored rather than added to a history documenting mental illness.
I have a neighbor who lives on her own that regularly forgets her husband is dead. She leaves the gas stove on. Is it that hard to hold the authorities accountable in documenting that history and certifying that (very sweet when healthy) lady as no longer qualified to live on her own?
To be able to say, "I diagnose you as sick, what you want is now invalid" is an incredibly powerful tool, and obviously open for abuse.
Just a few decades ago homosexuality was considered a mental illness. Your line of reasoning would justify involuntary "treatments" for homosexuality. (And in fact, this sometimes happened.)
Today, many of the homeless are likely suffering from schizophrenia. Drug-based treatments for schizophrenia have permanent, non-reversible side-effects, and lower the chance of recovery to basically zero.
Today, as a non-schizophrenic person, I can tell you that if I did develop schizophrenia, I would not wish to be treated with those drugs. Would that wish suddenly become invalid because I was suffering from mental illness?
To my mind, it's pretty evil to force someone to take a drug with permanent side-effects against their will.
If diagnosis were more accurate and peer-reviewed, with paths to release for all people, it may be more tolerable. But if someone can say "You're sick" and take you in, it's too dangerous.
- Statistical data on who is homeless and why - Data on how a given person's homeless life tends to proceed over time - Data from homeless people on how they view their lives + their "satisfaction" (whether they are mentally ill or not" - Data that attempts to predict health / satisfaction in the future from past circumstances
I'm sure some exists... but I don't hear much about it.
The article points to the value of data, by indicating that compiling a consistent history (across service providers) of a homeless person's history can make it very clear when someone is in the (extreme) case that they are not going to take good care of themselves in the future.
The (wonderful) discussion on this post goes through all the complexity of balancing respecting autonomy with promoting well-being. But even the best comments are anecdotes. I don't know if the greater evil (today) would be a) allowing people to destroy themselves or b) imprisoning them in a bureaucracy.
Understanding with data (top down overall + longitudinally) could give a sense for where the common cases are, and what cases we consider are very rare.
In criminal justice, we imprison innocent people. It sucks, and we will try to minimize it, attempting to "let 10 guilty people go free vs. convicting one innocent" But we don't go so far as to imprison almost no one.
By analogy, with better data, I would feel more empowered to have an opinion of what direction to push in here.
> These are sick people that need shelter and help
There is a large amount of literature on how said institutions didn't provide much help other than sedating people and subjecting them to procedures like lobotomy for diagnosis such as "mild" as depression.
or themselves
>I would find some middle road where it is not a crime, but a civil order.
In the past this road has lead to people being committed because someone just didn't like them. Broadening committal to people deemed not acceptable by society is a dangerous path.
Believe it or not many of these people have relatives and friends who do care about them, deeply, but are powerless to help them because in their delusions they have violently rejected their help. I've watched a friend of mine starve nearly to point of death on the street and be unable to do anything to help him other than take him to lunch whenever I could.
By this definition, everyone on welfare can be incarcerated in a mental institution at any time without cause..
Not mentally ill? Well, perhaps you are, we'll take you in for another screening.
This process has mostly been used on addicts and alcoholics (treatment or jail, drug courts), and sometimes works.
Here in Key West, you can also get a bus ticket somewhere else, presumably where the person has more of a support system (family, friends)... if you agree not to return. This solves the problem for Key West, anyhow :)
He was an incredibly intelligent and accomplished person, but, like all of us, had his demon. For him, it was robo-tripping; taking large doses of cough syrup to get a high. It had been going on for years, maybe even decades. The years of abuse manifested as a hidden mental illness; he had concocted an imaginary friend who he could visit whenever he was tripping. The two of them grew very close together. The relationship was complex, as was this imaginary person. For all intents and purposes it was another "intelligence" living inside him.
Eventually he tried to cut his "addiction". But when he tried to stop cold turkey, he realized not taking the drug anymore would mean never seeing his friend again. By this point, he had grown too attached. So he continued his now ritualistic highs.
One day he was taken to the hospital for attempted suicide. Amidst all of this was an underlying chronic depression. The depression predated the abuse, likely your classic case of the depressed genius. He was released very quickly, I think within 24 hours or so. But now more of his close friends, including myself, knew something was up. I had no idea any of the aforementioned abuse was going on, nor the extent of his depression (I knew he suffered, but didn't know it was bad).
After that event, he sat down with me and told me everything. It was a long, shocking conversation. The evening after was one of those cold nights you don't think you'll ever escape from. Like being lost at sea. At one point he showed me a bag. It was filled with pills; gel capsule cough syrup pills. Probably about two fists' worth of the stuff. He said that was his dose for later; the kind of dose he always takes.
I didn't say much. What could I say? He talked about everything; the drug, his friend, the hospitalization. When it was all over all I could do was hug him and tell him I was always there for him if he needed. He wasn't the kind of friend I hugged; we were more intellectual buddies. In fact, that may have been the only time I've hugged him. But, I think, despite my mind whirling from everything I had just heard, somewhere deep inside I knew ... this might be the end.
The next few days were tense. Our mutual friends talked over what to do; we began seeking advice on how we could get him help. Could we "commit" him to get mental help? By this point, he didn't want help.
During the long conversation with him, he talked about the hospitalization. How violated he felt by the event; being forcefully taken, poked, prodded, drugged, and held against his will. In many ways I had looked up to his man; he was older and smarter than me. So when I racked my brain thinking about whether we should force him to get treatment ... I just didn't know what was right.
When he wasn't under the influence, he was more or less normal. And if he did get treatment, he would lose his imaginary friend. I know that sounds weird. I could never describe this "imaginary" person the way my friend told it to me. But, you know how someone will be telling you about a person they've been hanging out with, and just by the way they talk and the look in their eyes you know they're in love (but don't realize it)? It was kinda like that.
So I could see his position. If he felt that strongly about this "illusion", how could I forcefully take it away from him?
It was only a few days before everything was over. He committed suicide. We didn't get him help in time.
I'm still not sure how I feel. Should we have more aggressively sought to force help upon him? Should I have said something during that long confession of his; protest his actions, tell him to get help ... or ... something?
And in general, what should you do when anyone is in a position like this? Clearly mentally ill, but so delusional that they don't want help ... what is the right move? Should we force help on them, like this article discusses? My friend's case would have been a little easier; he was a danger to himself. But I don't think the situation is any more clear cut.
I just wanted to share my story. I don't know if many people have had to face this kind of stuff first hand; had to make these kinds of choices. Or, at least, I hope most haven't had to. It's been many years since it all happened. I still cry sometimes when I think about it. I don't envy the workers who go out in the streets and try to help the lost and the homeless.
Feeling guilt about not being able to do more is a natural consequence of suicide. But it sounds like you were there for him, able to really listen. Think of how many people struggling with these sorts of problems don't have that.
A very important point is we do not start from the perspective that "these people are 'wrong' and need to be 'fixed'" instead we start from the lovely awesome assumption that these people are humans and are inherently useful. So we get them to do useful things and give them stuff that most people want.
Obviously, some people don't want to be part of any community, and some people would still prefer to live on the street even if they have housing. Such people can work there, but the whole package is really a niche for people who are looking for the whole package.
Basically: food, shelter, work, money, without any hassle at all.
If you are expecting something in return, or holding over someone (who may be delusional) a condition for help, you will not end up helping the people you set out to.
What are you referring to? What kind of work would they do specifically?
based on that plan, i expect you'll spend most of your money on lawyers, dealing with all of the legal / zoning / HR / irs red tape involved in employing people on that sort of basis, while tying it to their housing, which sounds like the sort of thing that's been banned in most cities for decades.
It's not tied to their work specifically, but it is some sort of arrangement where it is to some extent conditional upon their needs, wants and behaviour. It's a multifaceted suitability assessment, where the people we would help still maintain autonomy over what they get -- not like they are just applying to some large bureaucracy hoping to win a lottery.
the irs is going to see employees, subject to all the normal rules, and the city is going to see weird mixed commercial/residential property with strange density, and get all up in a fit.
don't get me wrong, i'd like to see you succeed, and i think the world needs some similar things, up and down the scale of a person's ability to handle the world. but there's a whole lot of bureaucracy that doesn't already have a form for what you want to do, and so will oppose it simply out of reflex.
(which is why i think your legal bills will be significant)
It was a disaster -- they brought a scourge of drugs, petty crime and serious issues like sexual predators and outlandish behavior that terrified the other residents.
These people need support, many are in the situation they were in because they lack a support network. That means investing in trained people and keeping them engaged for a long time.
From my point of view, I don't really see the need to get so emotional about this. Just see it from a level headed perspective and take some concrete steps. Thinking that such a sad situation can be improved is not something to get so angry about.
But to some extent I understand that...since it is an emotional issue, because it's such a painful one. I think it works to bring some calmness to the approach for excellent results.
Even if I try this and fail the people are not going to be worse off. So why has this proposal garnered your hatred? It really doesn't make you look bad that I have an idea about this and am bold enough to say it, and you don't have any ideas to speak of. So if it doesn't make you look bad, and it's not going to cause any harm, but might actually cause some good, why do you hate it? No need to be afraid of it. What this will be, if it is anything, will be like nothing that has come before.
So your reaction isn't about this idea. Your reaction to this idea is about you. While we could spend some more time discovering what about you it is, I don't want to spend that time so. You should discover what about this idea raises your ire so. That will be a really interesting discovery for you I think. That's what your reaction is about. You should work out why you feel like that.
And while you're doing that, the people who choose to want to contribute to making improvements in this problem and others can get on and do that.
Of course, this can quickly devolve into a workhouse or poorhouse; there's a black history there already. But I understand that that's not what's being proposed.