I believe the previous solution was to err on the side of allowing 24-hour involuntary psychiatric holds, with observation by a neutral doctor, and taking abuses of that extremely seriously.

In my friend’s case, he had actually set up permissions for the doctor, his family, and I to initiate such a thing, but after his episode started, he fired his doctor and was quiet for a month, which nullified the paperwork he had done to create a safety net for himself.

The law has a list of things that have to happen before the psychiatric hold if there is not such an arrangement.

Basically, the mental illness has to affect some number of life areas. I think this is the list, I might be remembering wrong:

- work - finances - shelter - self care (eating, etc) - family life / marriage.

It used to be that one thing on the list was sufficient. I think the current law is that a total of three are necessary, but not sufficient.

Risk of immediate self harm or harming others is a different path, but the person basically has to say “yes, I do plan to kill myself, or that fellow over there, officer” on camera for that to count.

Anyway, my friend ticked all six of these boxes, and that wasn’t sufficient. If the person is borderline coherent, don’t think anything really is.

(Nothing in this message should be considered medical or legal advice. Go talk to a doctor and a lawyer if you might need to know any of this stuff, especially if everyone is healthy at the moment.)

(Edit: upvoted sokoloff because this is exactly what everyone with any power to provide care says.)

> I believe the previous solution was to err on the side of allowing 24-hour involuntary psychiatric holds, with observation by a neutral doctor, and taking abuses of that extremely seriously.

We have a history of using this policy in multiple countries, and in each one the system was abused to torment and commit minorities, people (including children) who were deemed an inconvenience, and political enemies.

I say this as someone with a family member who went through a very similar experience as your friend. I know just how scary and frustrating it is, and the immense burden of care and worrying it puts on people who care about someone going through mental breakdown like that.

I wish there was a solution to this problem, but I don't know what it would look like.

In the US there was an experiment where a bunch of healthy people were sent for a temporary hold and evaluation, and something like half of them were declared insane for refusing to admit they were insane, and trapped until the experimenters intervened.

That's the Rosenhan experiment: https://en.wikipedia.org/wiki/Rosenhan_experiment

Rosenhan's paper itself ("On Being Sane In Insane Places") also makes for fascinating reading and is very readable even for laypeople.

In England you have an assessment with an AMHP (who is there to protect the rights of the patient) and two doctors. One is a specialist MH doctor with training on the law, the other knows the patient. They have to agree that the patient poses a serious risk of harm to themselves or other people, and that they must be detained in hospital for assessment or treatment. The AMHP asks the patient's nearest relative if they object to the section -- if they do object it becomes harder to detain someone.

You then provide free legal advice, and access to mental health act tribunals where people can challenge their detention.

You have independent regulators who provide some oversight, the rpess can report on it all, and of course the courts provide a final backstop.

There are problems with this, but it's pretty good.

We have short detentions for assessment. We have longer detentions for treatment. We have police powers to take someone from a public place to a place of safety for assessment. There's another police power where the police can take someone from their home to a place of safety for assessment, but only if they have a valid warrant.

Things which would have helped here:

- healthcare not linked to employment

- a housing-first homeless policy

- a compassionate aid policy that presumes that people who are asking for help need help, and starts providing help as soon as it is asked for rather than after a year or more.

Those don't seem like they have any major risks other than monetary.

I strongly disagree with the housing first policy. I tried paying for temporary housing for my friend, and things spiraled. The housing has to be conditioned on some sort of recovery plan.

Threat of homelessness is basically the only remaining lever the law allows in these situations.

The other two points are spot on.

I don't know your circumstances, and first of all that is a great and generous thing you did for your friend.

The one place I know of where a housing-first policy has been implemented, Salt Lake City (or maybe all of Utah?), doesn't just give homeless people a set of keys. They do assign everyone a social worker at the same time. The goal is to minimize the risk of what happened to your friend; that isn't good for anyone, including the person spiraling.

It's key, though, to start with a home (and a social worker). The wealthiest country in the world can do that for its people -- and it shouldn't be on private citizens, though that was generous of you.

A big advantage of institutions is to collect the long term learning and lessons into more effective actions. Trying to handle it individually is admirable, but it's at a huge disadvantage and without experience with multiple cases to know what might work better or worse for various people.

Folks have different sorts of needs, and those need to be addressed as well.

My ex was schizo-affective (had traits of both schizophrenia and bipolar disorder). He was on disability. His doctors did not want him living by himself. Some things were simply too stressful and he couldn't do all of it. He'd only cook instant food. He wasn't good at budgeting money. And so on. For a while after we split up, he had a social worker coming to his house for wellness checks. My friend worked a similar job for another hospital: SHe'd visit mentally ill patients and help them, sometimes shopping and whatnot.

There was no recovery for him, only meds. That's it. Only meds.

I cannot fathom how stressful it would be to have your housing and your safe space be dependent on taking your meds, especially when your meds need adjustment... and paranoia strikes up again. Every stressor simply complicates things.

Housing is the first step in a recovery plan. And if they refuse a plan, what's wrong with letting them have a cheap dorm room? Are we so spiteful?

What do any of those have to do with a patient who refuses to go in voluntarily for treatment?

They can foster hope, and try to strive for happiness without struggles of a simple toothache, crippling debt and outright usurious lending practices, while emptying a cold can of chili into chip bag on bus bench for breakfast.

Why not add unlimited resources to the list and call it a day? The problem here isn’t a lack of compassion, political will or information. The problem is the costs, largely due to the legal system which incentivizes litigation and high level policy debate for aggregate clinical outcomes that would benefit societies at the cost of individual liberty.

IMO--

In so many ways, America needs to start understanding that solutions to these problems have been explored and, just possibly, greater progress achieved in other countries... progress can be gleaned by studying outcomes from those countries.

It's easy to dismiss suggestions as having "its own set of risks and downsides", but in critical areas, America is significantly underperforming other first world countries and we need to get past the Not Invented Here syndrome.

It's not Not Invented Here syndrome.

It's Indoctrinated That Anything Socialized Is For Weak Moochers And Cannot Succeed Because It's Not Capitalism syndrome.

The current approach is not a solution, it's doing very little and saying you are doing something.

Describing psychotic delusions as 'reality diverges' is something or other, I have to say.

Of course we need to respect the rights of individuals, but it shouldn't be the case that family and friends are the first, second, third, fourth and so on interventions, there can be professional resources available.