This is a good question. I'm not a policy wonk or a lawmaker, so I'm not sure what exactly would be best in terms of crafting specific language, but right now a lot of people have difficulties even voluntarily committing themselves or getting insurance to cover the cost of in-patient care because potential care providers often say, "If you were a danger to yourself or others you wouldn't be fit to even bring yourself in for treatment, clearly you don't need that much help." It's often difficult for people to even be put in temporary hold without expressing some kind of violent thoughts towards themselves or others. This is one of the reasons why that current threshold is troublesome -- it makes it more difficult to commit all people suffering from severe mental illness, not just ones who are violent.
I don't think a simple, easy to remember metric like "imminent danger" is the way to go. I think there needs to be a way to holistically assess someone's current grasp on reality, similar to how a psychiatrist would perform an actual diagnosis on someone involving interviewing them and carefully looking at their personal history, and then deciding from there if that person would benefit from commitment. Obviously that is easier to do with someone who has brought themselves in for treatment and more difficult to do in an active crisis situation. Another complicating factor is that those who have a lot of experience suffering from severe psychosis can often work the system in ways that are not ultimately helpful for them. Jonathan Rosen talks about this in his book where his friend Michael Laudor, despite being in the throes of psychosis, would kind of put on an act when speaking with law enforcement or social workers, enough that he could present as, not sane exactly, but also not violent, and of course that happened enough times until he killed his fiance. It would be better if mental health care providers could actually ensure that people are taking their medications and if they could also be empowered to perform more thorough mental health screenings that don't just end with them throwing up their hands and saying "Well, that person is clearly unwell and unable to take care of themselves, but they didn't physically threaten us, so there's nothing else we can do."
Once again, you have hit all of the points so eloquently. Thank you for being kind enough to link my essay. Thank you for continuing to write so powerfully about this topic.
“My own proximal solution to this problem is to robustly fund mental healthcare, create more in-patient treatment centers that can more readily perform patient intakes without having to deal with the existing hurdles of health insurance and “danger to one’s self or others” metrics, and empower care providers to involuntarily commit those who chronically refuse treatment despite their clearly degrading mental and physical health.“
That’s not a solution. It’s a blueprint for a psychiatric police state. You want to build a massive prison system before we build enough housing for every person, including those who cannot pay a landlord. You want to explode the Medicaid budget before we increase the minimum wage or the social security allowance. And, you want to gut due process. Your “solution” would enable the state to cage the disobedient and inconvenient citizens along with the dangerous ones. In the span of one bad day, someone could meet your “degrading health” threshold for involuntary psychiatric commitment.
Any one of those “reforms” would cause widespread civil unrest. The most basic social contract between a free society and its people is the right to remain free in exchange for obeying the law. If that contract were terminated in an instant for some 15,000,000-30,000,000 people, the fallout would make a ward riot look like a Taylor Swift concert.
A psychiatric facility is not inherently cruel or inhumane. Involuntary treatment is not inherently cruel or inhumane. Jails and prisons, though they largely are, do not have to be cruel and inhumane. The fact that many are does not mean that we shouldn't improve them and make them more humane, and it certainly doesn't mean that we should abolish them altogether. A "psychiatric police state" is just so far away from our current reality of severely mentally ill people languishing on the streets with little to no options for getting the care that they need that it sounds utterly ridiculous to invoke it as a reason to not, what? improve our systems of psychiatric care? Give me a break.
I find it notable that these kinds of fears are proffered without offering some kind of alternative to the abject neglect and hurdles that are causing people suffering from severe psychosis to go on living immiserated existences. I grow weary of repeating myself in this comment section space, but I will do so here again: I don't need to be told that the power of the state can be used to pathologize and marginalize dissidents and other such malcontents. I literally have friends who have been surveilled and arrested for carrying out direct actions. I get it. But so what? What is your point in regards to the very real need to treat psychotic afflictions? Even in a socialist society, psychosis will always remain with us, which means that people will need psychiatric care, and sometimes (sometimes!) that care will have to be given without the consent of a psychotic brain in order to save the life of that individual and potentially the lives of those in their orbit. Literally any form of coercive power can be used for profoundly harmful and evil ends. That does not mean that we do not endeavor to create systems of power that actually benefit society. If that were the case, we should still be living in caves. The simple and banal fact that state powers can be abused does not by itself mean that we refrain from investing the state with certain powers. Do I want political dissidents to be locked up for life by an authoritarian state that has conveniently defined those dissidents as mentally unwell? Of course not. But I also don’t want people living and dying on the street because they are suffering from chronic delusions. And I can assure you, there are millions of people — right now — who are living and dying on the street because of their mental illness. There absolutely is not millions of people in the U.S. locked up in asylums against their will for being anti-capitalist. This doesn’t seem so difficult. It is quite achievable for us as a society to create and maintain a system of government-funded healthcare that can consistently and compassionately make distinctions between a schizophrenic and a socialist, between someone with a chronic psychotic affliction and someone who is just having "one bad day," as you put it.
If we housed everyone (as we of course should) people would still be psychotic. If we instituted medicare for all (as we of course should) people would still be psychotic, if we increased the minimum wage and social security allowance (as we of course should) people would still be psychotic.
What I am trying to make clear is that untreated psychotic afflictions are a very real problem, and there are solutions to that problem. A lot of the pushback on this simple view takes the form of people who either: don't concede that psychosis is a problem; don't recognize that there are proximal solutions, assuming that the intolerable status quo is the best we can hope for; don't recognize that involuntary treatment is sometimes necessary and good, viewing it instead as inherently beyond the pale. I stand in opposition to all of these views. I have yet to hear from anyone offering these pushbacks a solution for getting people the mental healthcare that they need even when they won't or can't get that necessary care.
Now, there is an essential discussion to be had as to how to go about achieving the reforms that I advocate for. I am not a policy wonk, nor am I an experienced organizer for legislative change. So I am largely an agnostic on the "how" of all this. But so many people refuse to even accept the basic contours of the problem, that I feel we have our work cut out for us just trying to get people to come to a broadly understood definition of the problem, which is what these articles of mine are attempting to remedy.
As for the notion of widespread civil unrest resulting from mental healthcare reform -- what? Are you really serious with that? Again, treating psychosis does not equal the gestapo. Even if it did, by some magical leap where healthcare professionals are suddenly confining and torturing political dissidents en masse, most Americans aren't even aware of the recent Prairieland verdicts, the indictments against Stop Cop City protesters, the imprisonments of fossil fuel protesters and other radical environmentalists, much less are they storming the castle over these abuses of state power. This is an incredibly docile population we have here in America. So even though I totally reject your supposed vision of the nation teeming with scary teams of orderlies in white coats rounding up people in the millions for being political dissidents, even if that were to come true I seriously doubt that anarchic civil unrest would result. If the populace were as ready to be mobilized as you claim, we would have seen largescale civil unrest already for the litany of affronts to civil liberties that have been carried out against us over the last twenty years. The 2020 uprisings notwithstanding, this nation has largely rolled itself over for every major infringement on our civil rights. I admire your optimism on this one point though.
*tenet, not tenant
how should the threshold be worded instead of "imminent danger to themselves or others"?
This is a good question. I'm not a policy wonk or a lawmaker, so I'm not sure what exactly would be best in terms of crafting specific language, but right now a lot of people have difficulties even voluntarily committing themselves or getting insurance to cover the cost of in-patient care because potential care providers often say, "If you were a danger to yourself or others you wouldn't be fit to even bring yourself in for treatment, clearly you don't need that much help." It's often difficult for people to even be put in temporary hold without expressing some kind of violent thoughts towards themselves or others. This is one of the reasons why that current threshold is troublesome -- it makes it more difficult to commit all people suffering from severe mental illness, not just ones who are violent.
I don't think a simple, easy to remember metric like "imminent danger" is the way to go. I think there needs to be a way to holistically assess someone's current grasp on reality, similar to how a psychiatrist would perform an actual diagnosis on someone involving interviewing them and carefully looking at their personal history, and then deciding from there if that person would benefit from commitment. Obviously that is easier to do with someone who has brought themselves in for treatment and more difficult to do in an active crisis situation. Another complicating factor is that those who have a lot of experience suffering from severe psychosis can often work the system in ways that are not ultimately helpful for them. Jonathan Rosen talks about this in his book where his friend Michael Laudor, despite being in the throes of psychosis, would kind of put on an act when speaking with law enforcement or social workers, enough that he could present as, not sane exactly, but also not violent, and of course that happened enough times until he killed his fiance. It would be better if mental health care providers could actually ensure that people are taking their medications and if they could also be empowered to perform more thorough mental health screenings that don't just end with them throwing up their hands and saying "Well, that person is clearly unwell and unable to take care of themselves, but they didn't physically threaten us, so there's nothing else we can do."
Once again, you have hit all of the points so eloquently. Thank you for being kind enough to link my essay. Thank you for continuing to write so powerfully about this topic.
“My own proximal solution to this problem is to robustly fund mental healthcare, create more in-patient treatment centers that can more readily perform patient intakes without having to deal with the existing hurdles of health insurance and “danger to one’s self or others” metrics, and empower care providers to involuntarily commit those who chronically refuse treatment despite their clearly degrading mental and physical health.“
That’s not a solution. It’s a blueprint for a psychiatric police state. You want to build a massive prison system before we build enough housing for every person, including those who cannot pay a landlord. You want to explode the Medicaid budget before we increase the minimum wage or the social security allowance. And, you want to gut due process. Your “solution” would enable the state to cage the disobedient and inconvenient citizens along with the dangerous ones. In the span of one bad day, someone could meet your “degrading health” threshold for involuntary psychiatric commitment.
Any one of those “reforms” would cause widespread civil unrest. The most basic social contract between a free society and its people is the right to remain free in exchange for obeying the law. If that contract were terminated in an instant for some 15,000,000-30,000,000 people, the fallout would make a ward riot look like a Taylor Swift concert.
Thanks for the catastrophizing, it's not helpful.
A psychiatric facility is not inherently cruel or inhumane. Involuntary treatment is not inherently cruel or inhumane. Jails and prisons, though they largely are, do not have to be cruel and inhumane. The fact that many are does not mean that we shouldn't improve them and make them more humane, and it certainly doesn't mean that we should abolish them altogether. A "psychiatric police state" is just so far away from our current reality of severely mentally ill people languishing on the streets with little to no options for getting the care that they need that it sounds utterly ridiculous to invoke it as a reason to not, what? improve our systems of psychiatric care? Give me a break.
I find it notable that these kinds of fears are proffered without offering some kind of alternative to the abject neglect and hurdles that are causing people suffering from severe psychosis to go on living immiserated existences. I grow weary of repeating myself in this comment section space, but I will do so here again: I don't need to be told that the power of the state can be used to pathologize and marginalize dissidents and other such malcontents. I literally have friends who have been surveilled and arrested for carrying out direct actions. I get it. But so what? What is your point in regards to the very real need to treat psychotic afflictions? Even in a socialist society, psychosis will always remain with us, which means that people will need psychiatric care, and sometimes (sometimes!) that care will have to be given without the consent of a psychotic brain in order to save the life of that individual and potentially the lives of those in their orbit. Literally any form of coercive power can be used for profoundly harmful and evil ends. That does not mean that we do not endeavor to create systems of power that actually benefit society. If that were the case, we should still be living in caves. The simple and banal fact that state powers can be abused does not by itself mean that we refrain from investing the state with certain powers. Do I want political dissidents to be locked up for life by an authoritarian state that has conveniently defined those dissidents as mentally unwell? Of course not. But I also don’t want people living and dying on the street because they are suffering from chronic delusions. And I can assure you, there are millions of people — right now — who are living and dying on the street because of their mental illness. There absolutely is not millions of people in the U.S. locked up in asylums against their will for being anti-capitalist. This doesn’t seem so difficult. It is quite achievable for us as a society to create and maintain a system of government-funded healthcare that can consistently and compassionately make distinctions between a schizophrenic and a socialist, between someone with a chronic psychotic affliction and someone who is just having "one bad day," as you put it.
If we housed everyone (as we of course should) people would still be psychotic. If we instituted medicare for all (as we of course should) people would still be psychotic, if we increased the minimum wage and social security allowance (as we of course should) people would still be psychotic.
What I am trying to make clear is that untreated psychotic afflictions are a very real problem, and there are solutions to that problem. A lot of the pushback on this simple view takes the form of people who either: don't concede that psychosis is a problem; don't recognize that there are proximal solutions, assuming that the intolerable status quo is the best we can hope for; don't recognize that involuntary treatment is sometimes necessary and good, viewing it instead as inherently beyond the pale. I stand in opposition to all of these views. I have yet to hear from anyone offering these pushbacks a solution for getting people the mental healthcare that they need even when they won't or can't get that necessary care.
Now, there is an essential discussion to be had as to how to go about achieving the reforms that I advocate for. I am not a policy wonk, nor am I an experienced organizer for legislative change. So I am largely an agnostic on the "how" of all this. But so many people refuse to even accept the basic contours of the problem, that I feel we have our work cut out for us just trying to get people to come to a broadly understood definition of the problem, which is what these articles of mine are attempting to remedy.
As for the notion of widespread civil unrest resulting from mental healthcare reform -- what? Are you really serious with that? Again, treating psychosis does not equal the gestapo. Even if it did, by some magical leap where healthcare professionals are suddenly confining and torturing political dissidents en masse, most Americans aren't even aware of the recent Prairieland verdicts, the indictments against Stop Cop City protesters, the imprisonments of fossil fuel protesters and other radical environmentalists, much less are they storming the castle over these abuses of state power. This is an incredibly docile population we have here in America. So even though I totally reject your supposed vision of the nation teeming with scary teams of orderlies in white coats rounding up people in the millions for being political dissidents, even if that were to come true I seriously doubt that anarchic civil unrest would result. If the populace were as ready to be mobilized as you claim, we would have seen largescale civil unrest already for the litany of affronts to civil liberties that have been carried out against us over the last twenty years. The 2020 uprisings notwithstanding, this nation has largely rolled itself over for every major infringement on our civil rights. I admire your optimism on this one point though.