07 June 2014

Mental health

And what amounts to our paranoia in response. I found this interview filtering through to my social media feed. And I found the answers given so utterly depressing that I felt I should eviscerate them more deliberately so as to feel better.

What signs should parents look for that differentiate a child who needs help coping from one who presents a danger to others?
"As a general rule, young adults who develop erratic behavior do so in response to either substance abuse or early symptoms of psychosis (schizophrenia or bipolar disorder). The most important thing to look for is a marked change in behavior: previously outgoing with lots of friends, now spends most of his/her time in bedroom alone; or a dramatic drop in school grades." 

Note this doesn't answer the question. This simply re-identifies the sort of people who need help coping socially, but does not identify the supposed danger signs to others. Likely reasons for this are as follows: 
a) there are no easy ways to differentiate who is a supposed danger to others. Even psychosis related mental ailments are not automatically dangerous to other people. 
b) parents certainly aren't going to detect them if someone is going to, but they will likely worry and overblow what signs and symptoms they do detect. 
c) psychiatrists get a built-in business model of seeing every teenager who is marginally sullen because of this. Which is basically every teenager. 
d) substance abuse is a bigger problem than any mental illness in relationship to violence and injury, and in fact can considerably amplify most of the problems that mental patients would otherwise have in dealing with any potentially violent episodes. Alcohol in particular. That subject matter was dropped in favor of others but at least got a nod to its existence.

Do therapists receive adequate training to recognize potentially dangerous patients?

"“Therapist” usually indicates a psychologist or social worker, although it may also include people with other degrees, including those obtained by mail order. The training of therapists, and their ability to evaluate an individual such as Elliot Rodger, thus varies widely depending on their training. California seems to have more than its share of mail order degree therapists." 

This read like : lots of people who are supposedly helpful mental health individuals are giving bad advice, so you should only see people who are "qualified". That may in fact be quite true given the status of our mental health system and its affiliated tendrils (prisons, therapists, etc). But it does not answer what kind of training is available that could recognize potentially dangerous patients. This is likely because there does not appear to be any such training available. Or at least what is available is not worth that much more than what is easily accessible information (eg, this person just shot or attacked multiple people, and the psychiatrist will be able to tell us how that happened, but not why it doesn't happen more often). 

The value of psychiatry is probably not in deducing these factors ahead of time correctly but in guessing more often than is true to be cautious and in particular, in having regular treatment and sessions for people with serious issues. Ideally its value is in helping such people to lead as normal of lives as is possible or otherwise cope with these problems successfully. 


This response tells us that our shooter probably had inadequate mental health care from what he apparently received, but that could be easily deduced by the paranoid and misogynist ramblings he posted. 


What strategies do people use to cover mental illness when confronted by parents, social workers, teachers, and law enforcement? Are there questions authorities should ask to identify a person attempting to conceal mental illness?
"Many individuals who are psychiatrically disturbed are able to “hang it together” for a few minutes when confronted by a police officer, judge, etc. I have had very psychotic patients appear quite rational for 10 minutes in a courtroom by focusing their mind. Patients with Parkinson’s disease can similarly suppress their tremor briefly by focusing their mind on it. Thus, it is unrealistic to expect a police officer to make a clinical evaluation, and such evaluations should include a mental health professional.
In Vancouver, at one time, they routinely had a psychiatric nurse go with the police officer to do such evaluations. A psychiatric nurse would be less threatening, could take [the suspect] aside and ask open-ended questions. (For example: “What is the worst thing that has happened to you in the last month?” or “If you did decide to kill yourself, how would you do it?”) The nurse could also, with his permission, use a cellphone to call his mother (or whoever raised the alarm), and/or his therapist at that time to get more information. Mental health professionals are more likely to pick up subtle clues that something is not right. To expect law enforcement officers to do this is unfair to them; they are not trained to do so and this is not why they became a law enforcement officer." 
I find this response absolutely fails on multiple levels to address the question:
1) law enforcement officers are very often dealing with people with serious mental disorders (including substance abuse problems in particular). These are people who may generate many complaints from the public, who may be homeless, who may be victims of crimes often (much more often than they are aggressive) or witnesses to them, and so on. They are common members of the community and probably more common members in the world that police will inevitably travel as a matter of course. 
2) law enforcement officers should therefore have sufficient training to deal with people suffering from some of the more common disorders and problems to be able to deal with these issues. This is not the same as discerning which people are likely to be violent-prone for a mass shooting for preventive treatment, but it is absolutely ridiculous to state that this is unfair to law enforcement, or that no expectations should be placed upon law enforcement in effect because "we haven't trained them". One expectation should be that they become trained. 
3) some law enforcement personnel should have additional training available and taken for dealing with specialized cases, or should have access to psychiatric assistance if they have such calls where they suspect that's the issue for an appropriate investigation and for the civil rights of the person involved to be protected. 
4) most law enforcement does not do this and their typical response to mental disorders is or has often become violent (in more than a few cases, it has been fatal). All of this is a serious reason why many people DO NOT or WOULD NOT or even SHOULD NOT go to the police when they suspect a problem of this variety. And thus becomes a further reason why a few people would slip through the cracks as they are unlikely to receive any attention and treatment to a potential problem. 
5) None of what was described as a method of response to the problem suggested to me that police, with an appropriate unit tasked to it, couldn't do some of this work already. They just don't have any training usually to do so. Asking open-ended questions and not appearing to be a police officer are not overly complicated methods of investigation. These are also not likely to provide cues that should tell us precisely what the issue is, only that more investigation is needed. That's likely something good police work could do already. 
Under what circumstances can a family member, social worker, or law enforcement officer have a person involuntarily committed because they represent a danger to society? With the recent spate of shootings perpetuated by people with known mental illness, do those laws need updating?
"Commitment laws vary by state. Details about the law in each state can be found on the website of the Treatment Advocacy Center. A rating of state commitment laws was published in February 2014. California’s commitment law is among the strictest, thus making it very difficult to involuntarily commit an individual like Elliot Rodger for evaluation. State laws need to be improved."
- In what way? What precisely as information was available that police lacked to act upon it (social media footprint/web search?) This question demanded a followup of what kinds of improvements are needed or being implied. 
I'm very, very skeptical that broader involuntarily commitment laws are a good approach and I find that effectively, that's already what we are doing. We're just waiting until people are suspected of committing criminal acts first to do it. 

My main skepticism to this approach is that a) police could use this as an over-broad way to "arrest" people, something I would want very strong controls over. Lawsuits that punished the officer and psychiatrist involved who signed off on it for example if they detained someone without a serious problem, and not lawsuits that punished the police department or the hospital. The persons involved should be held directly responsible for any civil rights violations they perpetrated in these instances so as to encourage them to be as careful as possible with this power. We do this only in limited basis right now for most civil rights violations (improper arrests or misconduct, read: lying) by police and prosecutors now. It should be expanded. b) I am very skeptical that psychiatry as a field is liable to identify with precision only those people who are dangerous and separate them from those who are not. Our information where it concerns the brain and psychology in general is sometimes sketchy and unreliable, our mental health professional skills are highly uneven, and I would stress that our approach appears to be an overabundance of caution where these matters are concerned which would lead to far too many people being detained in this way as would be appropriate to allow for, and c) that our current involuntarily treatment methods do not appear to be very successful or productive for many disorders. Many that could otherwise work rely heavily on the cooperation or independence of people who are otherwise irrational. Here there might be room for expanded scope in legal terms and especially better community approaches for mental health involving doctors, family, etc. I do not think this is what was being suggested versus having more involuntary commitments given the leading question that was used (this may have been the fault of the journalist involved more than the psychiatrist). 
Have we allocated the proper resources to help identify, treat, and potentially confine people whose mental illness makes them dangerous? If not, where do resources need to be directed? Are there enough facilities to treat these people?
"The answer is a resounding no. In California, like most states, we have closed 95 percent of public psychiatric beds. Even if a decision had been made to involuntarily commit Mr. Rodger for an evaluation, it would have been extremely difficult to find a bed. The public mental illness treatment system is completely broken. Rep. Tim Murphy in Congress has held hearings on the broken mental illness treatment system for the past year and produced a good bill which could improve it: The Helping Families in Mental Health Crisis Act. Every member of Congress should be supporting it."
- I would agree we have terribly allocated resources to the treatment and care of mental health. I would agree that often relatives or trusted and concerned friends may be important allies in the proper treatment of problems. I'm not sure I would necessarily support everything in that bill. But it's probably the only good answer given here. I do not think we have a population of dangerously mental ill people that exceeds 40k (in as far as they may be dangerous to other people), unless we include virtually all violent criminal actors and all substance abuse problems. I do think we could use more than 40k in-patient treatment facilities or especially much better out patient treatment as is suggested. 
Note also the bill he agrees with provides substantial funding for the training of police for mental health problems and suggests there are significant problems with these interactions as they now stand. Suggesting that this is in fact something that police should be expected to deal with on some level. If not being the appropriate legal adjudicators of the liberty of all sane and insane people alike, then they should at least know what the variety of insanity could be and be able to react accordingly. 
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