Throwaway05
6d ago
Thank you for sharing this!
I enjoyed that in a large part he seems to be sunk by the fact that he can't name his blood pressure medication.
This is vindicating to me, given the number of times I have asked a patient what life saving medicine they are on and gotten the response of "dunno."
Throwaway05
2d ago
Frequently (by no means all the time but often enough) that's grossly insufficient.
-Some patients remain essentially untreated. You don't need to take medication (there is however a slow process for forcing patients who are sufficiently dangerous). Nybbler murder patient may in fact want to murder no-one other than Nybbler, and behave more or less while in the hospital while refusing treatment. After the initial period further involuntary commitment involves a judge - the judge may say "well he hasn't done anything bad since he got here, maybe he won't murder Nybbler?" and off he goes. Walks out of the hospital, buys the gun, murder goes. This is not theoretical, it happens (sometimes even with mass shooting events but does also show up in the local news when the death count is low). Solution: force people to get treatment without their consent. Or force them to stay in the hospital until they consent. Both are significantly more rights destroying.
-Some patients are only dangerous when they use drugs. While intoxicated and for a while after they are a psychiatric problem but outside that the health care system has no control over them. People who keep smoking PCP and want to murder people while on PCP should probably not be allowed to own guns. This should be fixed by arresting people who use and sell PCP but society isn't really electing to do this these days. Solution: reengage the war on drugs. Not a popular option.
-Much more common and much trickier is that it is common for people to be committed, accept treatment, temporarily get better, and then relapse. They then become a threat again. Sometimes quite quickly. Much more quickly than any court process would go. Charitably (and in truth pretty commonly) this happens because medication works well at reducing things like hallucination and aggression but not the negative symptoms lack apathy and avolition. When your symptom is that you can't be motivated to take medication and you don't care if the other symptoms come back, well then it is hard to stay on medication. And then the risk comes back.
Making a public and credible threat to murder someone for reasons that are universally not given as acceptable (ex: for no reason at all or for reasons of delusion) should be exclusionary to owning guns. We aren't talking for political reasons or because the neighbor slept with your wife, we are talking because you are convinced the neighbor is Proxima Centauri.
Nybbler's issue seems to be (although he won't clarify it) that it didn't go through a legal proceeding. But opening up legal proceedings is a huge can of worms.
Let's say someone (police, healthcare worker, concerned person, whatever) can open a complaint about someone's safety to own weapons. That's time consuming, expensive, might involve temporarily seizing guns or the person, will involve litigating if expression of political beliefs counts... way more abusable than present state.
The fact of the matter is that the vast vast majority of people who are involuntarily committed* really should not be allowed to own guns. Failures are rare. Should you find one (for instance someone who did a shit ton of PCP for ten years and then spent 50 years not using PCP and wants some guns) the expungement process works pretty well.
The modal involuntary patient isn't actually suicidal or homicidal, instead they are something like a schizophrenic who is so severe they just can't feed or care for themselves. Someone that disorganized isn't safe to own anything remotely dangerous, and if they had the financial ability to own a car (most don't) they probably shouldn't.
*assuming you agree with the suicide end of things, that's a bit trickier.
Throwaway05
1d ago
The process is somewhat individual and adversarial. In NJ the way it works is more or less this - somebody has to be concerned about the patient (usually a family member, a concerned bystander, cops walking by) the patient is then taking an ED or Crisis Center on a temporary hold, at which point a social worker has to see them and think they need to be committed at which point they are seen by two physicians who have to feel it is appropriate. Individuals involved can be sued, fined, lose their license for abuse and so on. Then afterwards there is an expungement process. If the patient is held for an extended period of time without discharge then they have a formal court hearing that can and will result in release from the psychiatric hospital.
Obviously there is some abuse and laziness in the process, most typically the second physician would be like "eh I wasn't there, I'll assume the first doc was correct."
Ultimately this involves multiple trained professionals with skin in the game to make the determination that someone needs to be committed and they can always go through a court process afterwards.
I think some of the value here is that most people who end up committed don't have the functional status to do much of anything. If you make it opt-in most wouldn't, and wouldn't be able to get expunged. I'm fine with a more robust way of people getting their rights back but it has to be done in away that isn't too egregiously expensive and defaults to no because of how dangerous a small subsection of these people are, which is hard to convey if you've never seen them.
Crisis centers do occasionally catch people who will explicitly say that they are interested in killing people (in a sociopathic way) and loading them down with rights restrictions before they get started in an unalloyed good.
Hope all of that makes sense, typed fast.
Some other stuff: -While most doctors aren't anti-gun they aren't committing people purely to get them away from their guns unless the doc has concerns for threat and its therefore appropriate. This is because these settings are overworked, their aren't enough beds for those who really need them, and the hospital doesn't get paid if the insurance company doesn't think the patient actually needs to be committed and that rolls onto the doctor's head. In the worse case scenario no psychiatric hospital will take the committed patient because they clearly don't need psychiatric care and then the ED comes over and stabs the psychiatrists 80 million times for taking up a bed while someone is bleeding to death in chairs.
-Average disorganized street homeless person is harmless other than the inability to care for themselves even if they are vaguely threatening, so they tend not to get taken in unless they are actively harassing someone or committing some other crime like trespassing.
Throwaway05
1d ago
It actually doesn't, as in the case I know where someone took a prescribed drug which caused psychotic symptoms. But even if that were so, a lot of things do. Showing some level of poor judgement and insight and lack of responsibility is not per se grounds for revoking a fundamental right.
I don't think we are going to get on the same page about this, but as a fact matter - if your friend was psychotic under the influence of a substance at that time he had poor judgement and insight, if they were committed involuntary (the correct response to oh holy shit the walls are talking to me is to you know, get help).
One of the challenges of managing society in general is what to do with people who are "fine" most of the time but dangerous while in a certain state (like decompensated mental illness, tripping balls, or just pissed off).
Throwaway05
4d ago
The way states usually handle this is that the person has to have some thing happen like a: has a psychiatric illness b. is a credible threat to themselves or someone else.
The presence of criteria for a psychiatric illness is important here and does most the political protection.
A really common teaching interaction is something like "haha, yeah man this patient is delusional because he is Trump supporter and thinks Obama isn't a citizen" attending puts on a very serious face "no, absolutely not. Political beliefs are not delusional unless they are totally culturally dystonic and fixed, the fact that he won the election is proof that is isn't delusion blah blah...."
Psychiatry is in general a pretty pozzed specialty but they don't fuck around when it comes to that kind of stuff.
You will absolutely see patients get discharged who are odious, violent, domestic abusers, substance users and all kinds of other crap because they don't actually meet commitment criteria and aren't psychiatric.
Now you are more like to see something like "this patient does meet commitment criteria yet we'd usually let him go because it's probably safe to do so however he was using racial slurs towards the staff so in he goes." This is unprofessional but still unfortunately legit.
Throwaway05
6d ago
Reading between the lines (and using some experience with the interaction between medicine and the legal system) my suspicion is that the court and multiple involved parties are aware of this and are more or less working together to block this guy in a paternalistic but likely ultimately wise way.
Throwaway05
9d ago
All of this below is somewhat moot in the sense that I'm not convinced that Ellison had Bipolar.
Disturbances in cognition exist on a spectrum from "this is not recognized pathology and is just my personality structure" (like a preference for scrambled eggs, a love of baseball, or being an asshole to your girlfriend because you are insecure about your small dick) to "this is purely something with an organic cause and blaming the person for their behavior is asinine" (a classic example benign example is a granny who is violent in the hospital because she's delirious and thinks she's is in a Nazi camp because of a UTI, a classic scarier example is someone who engages in a mass shooting because they have a golf ball sized tumor pressing on a few key structures in their brain).
Cases of the former are much more legitimate to blame (whatever that means) if love of eggs cause problems. Realistically insecurity about the small dick requires some sort of sex therapy or something if the person wants to stop hurting others and have a bit better of an experience of life.
Murder granny gets put in restraints and we treat her UTI and then everyone goes about their business and forgives her afterwards.
When it comes to things in the middle of those two extremes (that is, classic mental illness) we have a similar range. On one end you have personality disorders, like borderline personality disorder. These are in truth diseases of personality construction and really tease at what a "disease" is. It's easy to not feel bad for them (although I encourage you to) and this is true to the point where people don't want to give the diagnosis because of stigma (they give bipolar instead, relevance to Ellison?).
At the other end is one of: schizophrenia, schizoaffective disorder, and bipolar disorder. You could debate which one and they are certainly interesting and have interesting impacts on how much sympathy and guilt we should feel (what do you mean a symptom of the disease is that he doesn't think he has a disease and that's why he doesn't take medication and then ends up hurting people?),
True Bipolar 1 with psychotic features is the most stark here. Again I doubt Ellison had this but this the most sympathy you can have. This is a person with a monster inside them that comes up abruptly and severely because they run a 5k and their metabolism of their lithium changes.
They go from total normal nice person to a violent felon who doesn't sleep, spends their entire family's money and does X,Y, and Z ends up in jail with HIV and then gets started on medication and then goes completely back to normal.
Some people do things that put them at higher rate of an episode, but many people commit no mistakes and still lose.
Living with that should increase sympathy, no?
Most people aren't as stark as the straw patient above, but that is what it can be like.
Throwaway05
5d ago
I understand that drug names are not necessarily intuitive and while they have some tricks those will be impenetrable to patients.
That said, you need to know what you take, when, how, and why - otherwise you are at significant risk of increased bad outcome (although this obviously depends on what conditions you have).
What we usually recommend the elderly do is have a sheet with that information written out and store it in your wallet so it becomes easier to read out, can be retrieved if you are not arousable and so on.
This advice is good for anybody however.
With respect to this specific patient - we see a class of older men who have a large number of medical problems and put no effort into understanding what those are for, what they are doing about them, how to avoid making them worse and so on. While some of these people are stubborn or anti-medication most just have very low conscientiousness. Not ideal for a first time gun buyer at 80 something.
Throwaway05
14d ago
I have to imagine that the Dems have gotten very good at knifing each other for perceived thought crimes and insufficient demographic achievement. Only those who have been around long enough manage to avoid this through the accumulation of political power manage to survive in this environment.
Too much eating their own.
I do know a lot of young dems who in other times would be stepping up, but they seem to be too white and/or male and therefore stick with the think tanks or party strategist roles (and lead the elders into unpopular decisions).
Throwaway05
2d ago
Would you feel more comfortable with this process if we were able to produce date that illustrates that patients admitted with homicidal ideation are equally or more likely to kill someone as felons?
Fundamentally we need to establish what level of problematic behavior disqualifies from gun use. Some amount is clearly appropriate there are people dumb or crazy enough to say "if you let me have a gun I'm going to kill X." Clearly they shouldn't be allowed to. Felons? Stickier not every felon is likely to kill someone but it's a good broad category. You could attack this laterally by making assault on healthcare workers a felony and charging it 100% of the time, but that would be even more overkill - it happens a lot and we try and let it go because a good number of people who do this aren't likely to cause trouble or are likely to cause a minimum of trouble.
While my co-workers (of most non-surgical specialties) are certainly politically motivated at times, and are unlikely to write a letter in support of someone owning guns because they don't believe in that for political reasons....and at the same time they aren't going to abuse the commitment process for political reasons. I could say its because of historical abuses leading to lots of ethic changes on this, I could say its because of the increased lawsuit risk, but realistically a large chunk of it is just because it's so infrequently anything other than intensely obvious (at least outside suicide, suicide risk gets a bit stickier).
Patients who are sick tend to be really fucking sick and unless you've seen it it's hard to understand. Your usual crazy schizophrenic homeless person wandering around on the street was deemed safe to go home. How bad do you think the ones who get dragged in are?
Throwaway05
2d ago
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Our judicial system is predicated on people not actually going to trial these days. Are you willing to accept the increased cost in taxes to do this, or more likely - a coercive structure that would necessitate a "plea deal equivalent." If so how much financial drain on society is acceptable to you?
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What is special about jury trials over other processes? If someone does a bench trial is that acceptable? If a judge rubber stamps a psychiatrists recommendation (the likely outcome of a push for a trial process) is that acceptable? How do you want this to actually happen? This is not a simple logistical thing you are suggesting.
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Being involuntarily committed requires some level of poor judgement and insight and lack of responsibility. Sometimes it is obviously disqualifying "I'm going to kill my neighbor doc" sometimes it is debatably disqualifying "I'm going to kill myself doc" (as feelings on suicide are complicated, even if our society has staked a view on this topic) sometimes it is something more like "I need you to calm down so I can help discharge you" "fuck you bitch cunt go fuck yourself" (in the setting of clear threat to self or others). A pro-2A MAXIMALIST might have no problem with someone who is overtly dangerous, foul tempered, and irresponsible owning a gun. Fine.
BUT.
You need a plan for individuals who are extremely likely to commit violence. Some patients are likely (where likely could means something like 30-70, not a baseline 2% risk of committing a murder) to commit violence. An example is ongoing escalatory stalking and harassment behavior. Seizing their guns and/or preventing them from buying guns gives the victim options while other social processes (like moving away, a restraining order and violations of the same leading to jail time) come into play.
What do you want to do to prevent Nybbler killing man from killing you. He gets discharged by the judge from the Psych hospital because he hasn't attacked anyone in the hospital. The Psychiatrist has a duty to warn by law to tell you hey I think this guy is at high risk of killing you. Guy goes home, everyone knows he is going to go kill you, how do you stop him? If you call the police they'll say "has he done anything yet?" or maybe "file a restraining order." That's shitty.
This is not theoretical. I've seen patient situations similar to this where the whole hospital goes "shit that guy is going to kill someone" but we can't do anything about it. Then we read about it on the news or treat the victim.
That's with the current state. It gets worse with guns involved.
This is a common sense restriction.
I suspect your issue is of the cathedral and woke politics - you don't trust Psychiatrists to appropriately judge if someone is really in need of an involuntary commitment. I'm sure they get it wrong sometimes just like felony convictions, but:
Can you produce any evidence that people getting guns being taken away from them because of involuntary commitment inappropriately is occurring with any degree of frequency?
Throwaway05
4d ago
Some people will give us that info but it's usually pretty useless as make and manufacturer issues mean that the level of variety is high.
Throwaway05
3d ago
Absolutely, and while overt delusional beliefs are what pop to non-medical people seeing or hearing about these patients, the real problem is the negative symptoms of schizophrenia (often manifesting as a total inability to care for oneself in a functional way). That is much less exciting but more important for commitment purposes a good chunk of the time.
I think a lot of the doubters here would be way more comfortable if they had a chance to stay in a city crisis center for five minutes.
Throwaway05
6d ago
While each patient is different, much of what you alluded to in your description of events pattern matches to a subset of patients struggling with the way their personality interacts with the world, depression, and anxiety. Modernity blows and that's part of it.
Treating those things through a psychiatric lens is lower impact and cheaper/less risky than more direct intervention, which you will always find people willing to do.* The former works just fine with appropriate buy-in.
However since much of this is likely mediated by modernity...it is also not shocking that you feel better by finding some other way of viewing the world and your experiences.
Be careful with your approach however, you want to make sure it is well formed and can sustain itself should you have more stressors in the future.
*Proceduralists will often operate under the assumption that adequate preparation and work up has been done before their involvement. This is not a good assumption, and ultimately these physicians are those with hammers looking for nails.
Plenty are more diligent and careful but they tend not to get sent more marginal cases for a multitude of reasons.
Throwaway05
3d ago
I see Tchaikovsky come up on /r/Fantasy and /r/PrintSF quite a bit, but almost nobody ever mentions Shadows of the Apt, which I still feel is his best work.
Throwaway05
5d ago
It's usually more like "do you have any medical problems" "no" "any history of heart disease, high blood pressure, diabetes?" "no" "what are these scars for" "Oh I had a triple bypass in 2003 and I'm on 8 medications for all that."
Throwaway05
3d ago
So you want to pay the taxes required to run a criminal grade trial on everyone who is involuntary committed so that they can have their guns taken away by a jury of their peers. This would be expensive in a pure trial sense and because it would be slow people would be held unnecessarily - if you can go home after 4 days because the medication worked but you need to stay in the hospital (or be dispo'ed to jail/prison) for ....however many weeks to months it takes to hold an actual trial.... isn't that a worse violation of your rights?
Throwaway05
4d ago
To be clear: you want the state to summarily execute between 5-10 percent of the population because of the presence of severe mental illness?
Throwaway05
4d ago
The legal system in many places in the U.S. has abandoned intervention when a problem is a psychiatric matter and not a criminal one. Some of this is clearly inappropriate such as situations where the police are exhausted or the DA refuses to get involved. Sometimes it is appropriate, if someone is a chronic schizophrenic who has lost touch with reality and is violent then it's not a criminal problem, the guy is obviously not guilty by reason of insanity.
The person does not belong in jail they belong in a state hospital, this issue in part being that the funding for those beds has been taken away so traditionally these days they go to jail instead (it's just not the correct disposition).
Throwaway05
4d ago
I frankly have no idea how the judge in question here can honestly take a look at a forty-year period with no criminal history or further interactions with the mental health system or criminal justice system,
I think the implication of the proceedings was that this was not true, clearly wasn't true, and the court didn't want to waste time and money on sorting it so used other procedural grounds to close the matter.
Most people who fail in these kinds of proceedings are so allergic to basic competence and not being an entitled asshole that nobody who actually witnesses the situation feels bad. In the same that you look at most police encounters and go: "Should he have beat his ass? No. Did he absolutely earn it? Yes."
Most principled third parties read about these situations and fear some authoritarian judge taking rights away (which does happen) but the vast majority is "please give me something, anything to work with.....okay I guess you won't."
Throwaway05
4d ago
I think you can probably draw a line of separation between "normal" people who have personality traits, tendencies, hobbies, and political views I do not like and people who have severe mental illness (or an episode of the same with increased risk of recurrence).
Admittedly this guy was a lot further back so that the standards were different then they are today after some testing and improvement, but you have to work very hard to earn an involuntary stay and be very poorly behaved. Almost ALWAYS it involves true serious mental illness such and Schizophrenia, Bipolar disorder, severe Borderline, or MDD with suicide attempt or suicidal ideation. Or. It involves someone who is so unpleasant, uncooperative, violent, etc. that they are almost always a dangerous criminal they just might not have gotten caught yet (and the latter bucket is much less common).
If you are a threat to yourself or someone else in a real and foreseeable way you will likely be so again and the amount of danger is quite a bit higher. This is not "I dislike Nazis and they could do bad things!!!" this is "30% chance of murdering someone."
Throwaway05
4d ago
You have not proposed an alternative.
If your neighbor goes off of his medication and keeps following you around as you leave your house saying "Nybbler you raped me, I'm going to shoot you."
What do you want to do with this guy? Sure you could get him committed, but he'll be admitted, get stabilized, go home and go off his meds again and then go buy a gun and shoot you.
Especially in NJ the cops won't get involved because it is clearly a psychiatric matter not a criminal one.
Throwaway05
6d ago
They get diagnosed with fibromyalgia, CPTSD, hypermobility/EDS, or early onset arthritis. You give up hope they’ll ever be normal.
One of these is (superficially at least) not like the others and that also reveals the likely cause.
I think it is important to emphasize that to some extent we (western medicine) know what this kinda of life experience is about and how to treat it for quite a few people, and at the same time people are not excited about what needs to happen.
This is tough.
I imagine you've had this conversation before and likely are not excited about it, but it must be said both for you and anyone who happens to reading.
Chronic pain comes from a variety of places yes, but absent a physically traumatic event it is often psychiatrically mediated (and things like TMJ point to that). If it is not psychiatrically mediated, then psychiatric care is often important because chronic pain can cause psychiatric dysfunction (ex: depression from being in pain all the time). Either way - part of your care should involve sustained psychiatric follow-up and that would likely improve quality of life.
It is not uncommon for patients with stories like yours to not be down with this.
Often it's because the experience of pain is labeled in some way as "all in your head" and that gets mentally converted to "not real." Well it is real, it is pain those kind of patients are feeling that can respond to treatment but that treatment is generally things like lifestyle modification and psychiatric care and people want a procedure to be done or a "real diagnosis" to be dropped instead often because its simpler or more ego-syntonic.
Some doctors will take advantages of this because they have a research base stating that certain stuff they can bill for will work (and it can) but it also provides risks and has tangible financial costs. That doesn't mean it is the best thing for people (or the best use of resources).
I hope you are better and continue to get better than that but if you are unsatisfied with where you are the best thing you can do for yourself is seek psychiatric help, cases like your own almost always benefit from psychiatric assistance.
Throwaway05
5d ago
I will freely admit that sometimes places are a little "soft" with commitment (or lazy) but in general (and uniformly in busier places because resources are scarce) systems are very good at following the law, which varies by state by state.
In essence though the idea is the person needs to be a danger to themselves or others. The way that works out in practice is significant, imminent danger. You might say you have suicidal thoughts, but unless you have a plan and a situation which makes implementing that plan easy and likely then you'll get sent home.
When it comes to homicidal thought content its not "i'm going to kill my wife" its "I went out an bought a gun because I want to kill my wife because she is cheating on me" (and she is not in fact cheating, that's a delusion).
Putting aside the suicide end of things, you basically have to be having something (psychiatric) going on in your life that makes you likely to kill somebody. That gets taken seriously because a lot of these people don't get caught and end up murder suiciding, killing people, and doing things that end up in the news. Getting treatment on board or removing guns from the equation when they present themselves is huge.
The best predictor of future behavior is past behavior. Even with that in mind some people do get discharged from the (medical) hospital after a suicide attempt. When done properly (which is admittedly sticky) the burden for commitment is high. On the homicidal end of things you can credibly be planning to shoot up a school but if it's not psychiatric in nature...off you go (although some will make exceptions for this for the obvious reasons).
Inability to care for oneself is part of the assessment but that almost only comes up with people like chronic schizophrenics who can't feed themselves and so on.
Basically the idea is that (like with a felony) you've had an event that's so bad that it greatly contorts your actuarial risk of bad behavior such that abridgment of your personal rights is appropriate in order to protect others. That's fundamentally what a commitment IS, so taking away guns is not far off from a commitment itself.
To add to these examples, in later rounds of the US physician licensing examination (USMLE Step 3) they will sometimes ask questions which are designed to be novel - no way you know this specific fact or have seen it in a board prep resource. You are then asked to determine what would be the most likely answer based off of your understanding of the underlying biology and so on.
These are hard to do so you don't see too many of them, but it is possible.
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