
What to do with mentally ill homeless people who refuse help? - JumpCrisscross
http://www.latimes.com/local/california/la-me-lopez-gravely-disabled-0328-story.html
======
lisper
About ten years ago I spent two years on the streets of Santa Monica,
California making a documentary film about the homeless people there. This is
a clip of an encounter I have with a schizophrenic person on the first day of
filming:

[http://graceofgodmovie.blogspot.com/2012/01/i-am-super-
danny...](http://graceofgodmovie.blogspot.com/2012/01/i-am-super-danny.html)

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/](http://graceofgodmovie.com/))

It's a very complicated problem. But involuntary commitment to mental
institutions is absolutely not the right answer IMHO.

~~~
wu-ikkyu
How is involuntary commitment legal under the constitution?

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.

~~~
rtkwe
The constitution doesn't guarantee/require a trial by jury outside of criminal
cases. Since involuntary commitment is not a criminal case it only requires
due process which is simply a normalized legal framework. For commitment
there's hearings with judges and legal council for the patient which meets the
requirements the Supreme Court has laid out.

~~~
wu-ikkyu
After rereading the bill of rights I see your point, though it still seems
like a very nuanced loophole that can and has been used to supralegally
imprison and abuse social deviants (i.e. political dissidents in the USSR,
marijuana smokers in the US).

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

~~~
rtkwe
Well yeah, the constitution is far from airtight and largely relies on the
courts to fairly uphold the spirit of many of the clauses rather than a strict
word by word meaning. And it's a fair way to write the founding document of a
nation because it's impossible to codify every little case in a way that's not
fatally brittle within 50 years.

(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.)

~~~
wu-ikkyu
>PS: Imprisoning people for smoking pot isn't a good example here because it
goes through the normal criminal system.

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.

------
hprotagonist
This is one of those situations where broad-strokes rules just don't help very
much.

>"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.

~~~
mabbo
> 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.

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.

~~~
dangerlibrary
You are describing an extreme form of mental illness that is not as common as
more treatable / manageable forms. If all "mentally ill" people were as
incapable of cognition as you suggest, psychology and psychiatry would be very
sad, hopeless professions.

~~~
got2surf
True, but in the article, both Partovi and Ruffin cite examples of clients who
"claim they own a house, or that a relative will show up any day now", despite
being injured/homeless/exposed.

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.

~~~
galdosdi
Yes, but you and the grandparent commenter seem to treat it as black and white
-- either they are sane, or ALL logic has gone out the window. Many (most?)
actual mentally ill are not like that (spoken from first and secondhand
experience) -- SOME logic has gone out the window, and there is room to
"negotiate" or "convince" in alternate ways. But that requires getting to know
them, caring, spending enough time to earn some trust and understand more what
kind of entreaty would most appeal to them.

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.

------
tiku
Here in the Netherlands we let them live amongst normal people, we then wait
untill they stab someone or set their house on fire, because then it is clear
they are a danger for society. Oh, and because of cutbacks the government
demands that these people pay some cash for their own pills, but these people
often don't have a lot of money, so the problem solves itself. Just don't live
next to them.

~~~
throwasehasdwi
The best solution to a homeless problem is to move them somewhere else and
make your location less attractive. You can't cure the homeless and crazy and
trying to a waste of money. Either put them back in mental wards or accept
that they're going to live on the streets and put them somewhere they won't
bother anyone.

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.

~~~
jdbernard
To all of the those who have down-voted this comment, please engage in dialog
and don't just down-vote. _throwasehasdwi_ is speaking from personal
experience, directly to the question being discussed. If you do not like
either of his solutions, what would you advocate instead? Is the status quo of
persistent homeless acceptable in your eyes?

~~~
throwasehasdwi
It's still positive karma but barely. Honestly anybody that says you can
"cure" or "treat" the homeless has never dealt with them. In a wealthy society
like most western countries you don't stay homeless for long unless you're too
crazy to work.

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.

~~~
Nomentatus
Don't discount too ill to work. Especially if a diagnosis has been missed
which is very common. Although these homeless people are more likely to be
rescued in one way or another, in time.

~~~
throwasehasdwi
I don't think those too ill to work are homeless for very long. They either
find a way to get medical treatment or, most likely(in the US at least) just
die.

------
dilap
> “treatment is a right,” and that “to withhold treatment is cruel.”

That's quite the Orwellian double-speak for incarcerating & drugging people
against their will.

~~~
Datenstrom
I agree but I have a close family member who has been struggling with
something similar her whole life. Luckily between disability and family she
has never been homeless but for about three decades she was only part time
living in reality. It would take getting arrested for making a scene somewhere
and court ordered back on medication for her to come back. Luckily she has
been doing awesome for long time now, even holding a volunteer job, not sure
what the change was. If she was never court ordered I don't think she would
have ever came back.

Then again I'm not sure who can be trusted to decide if someone is making
decisions based on reality or fantasy.

~~~
throwaway7767
As a counter-anecdote, I know a mentally ill person (mostly functional,
luckily, but he gets paranoid delusions during the worst times). His family
pressed the doctors hard to have him involuntarily committed one time since he
refused to go. From what I can tell, the primary effect of that is that he now
has an intense distrust of doctors and those family members, and it would be a
lot harder for doctors to help him now, even if they tried to approach him
with more empathy.

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.

------
bannisterp
I live right in the middle of a hotspot for "street people" in SF. I struggle
internally with this question daily, because I see many mentally ill people
roaming the streets just outside my apartment. I've run the whole gamut of
solutions and emotions for the past 5 years, and I can only come to this
solution: let them refuse treatment, but make living on the street the least
viable option for them.

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.

------
1_2__3
This has always stuck with me. When I was a lot younger, in the early 90s I
was dating a guy who was pretty high up in Washington state's DSHS. I remember
him saying that massive cutbacks were forcing all the institutions they had
left to close. I asked him naively what the plan was for everyone who was
going to be released and he said "Nothing. There is no plan. There're just
going to live on the streets."

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.

~~~
Nomentatus
I remember around then being a policy analyst for the Mental Health department
of a government and being told (from above) that lots of money would be made
available for services in the community once institutions were closed - but
knowing perfectly well that it was a bald-faced lie at the time, given which
political party was in charge, and their record. As one example, the Social
Services manual at the time made it a firing offence to reveal to a client the
existence of an available service or entitlement that the client didn't
already know about. In print. Or to publish any part of the (quite official)
manual.

------
Fricken
Nature doesn't deal everyone the same hand. Society says we should all be
treated equally. The laws of nature are absolute. The laws of society are made
up, and exist only in our minds. The mentally ill and chronically homeless
really bring out the dissonance between these two systems. We can exasperate
ourselves and flounder about helplessly. We can leave these broken people on
the street. We can round them up and put them in a junkyard, out of sight and
out of mind. Or we can pretend we can fix them up and get them working again,
even though we can't. About once a week or so the solutionists of HN go
through this routine.

------
Kattywumpus
You mean, "What should the state do?" That's a different question than what
ordinary human beings should do.

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.

~~~
jdbernard
First, I agree with you. Making a policy of judging (often poorly) the state
of mind of other people and then forcibly stripping them of their rights based
on that decision is a dark road.

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."

------
meri_dian
>"Celina Alvarez, executive director of the nonprofit Housing Works, said the
group needs to make clear that it has no intention of abusing the rights of
those with a mental illness or rewriting the law governing involuntary
treatment"

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.

~~~
colechristensen
This is a difficult avenue to walk because it's not very hard to define
everyone not doing what you think is right as mentally ill and no longer
deserving rights or choice. (see about half of dystopic science fiction)

~~~
JumpCrisscross
> _see about half of dystopic science fiction_

See Alan Turing.

------
marojejian
Better data would dramatically improve this situation:

\- 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.

------
notliketherest
For the truly mentally ill, reopen the institutions, where they will be safe
from harming themselves and others. This will drive down costs tremendously on
these cities that suffer from chronic homelessness. Have we got away from that
whole 1960s, "One Flew Over the Cookoos Nest" notion that mental institutions
are nothing more than jails and that these people are just following their own
"movies" and just need to be "let free"? These are sick people that need
shelter and help and cannot do it themselves.

~~~
pyre
While many of these people need help, the institutions were closed because
they were rife with abuse. It's a playground for predators. If their victims
attempt to speak up, you have the choice between believing the "sane" person
or the person that is so mentally disabled that they need to be in an
institution.

> 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.

------
joshuaheard
They need to change the legal standard for involuntary commitment to a psych
ward. At present, the standard is that as long as the patient is not a danger
to others, they are allowed to roam the streets at will. I think a better
standard is to broaden it to where if they can't take care of themselves, they
can be involuntarily committed. That used to be called "vagrancy" and was a
crime. I would find some middle road where it is not a crime, but a civil
order.

~~~
nickpinkston
If they're not a danger to others why not allow them to do what they want? So
you can be more comfortable?

~~~
jdbernard
In my experience it's very hard to prove to the standard required for the
authorities to intervene. Basically you have to wait until they have already
hurt someone before action can be taken. And it's even worse if they are only
a danger to themselves. Worse still if they are simply incapable of sustaining
themselves rather than actively suicidal.

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.

------
bbunix
The key here is "refusing help". In the US it's pretty well one of our basic
rights unless we're a danger to ourselves or others. There are really only 2
choices, establish enough trust to encourage the person to receive help, or
wait until their behavior violates the law, at which point they've forfeited
certain rights and treatment of some kind can be mandated.

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 :)

------
vondur
I'm noticing here in California, many of the mentally ill homeless simply
ended up in jail, where they are given some level of care. However, with the
recent mandated Federal court order to reduce the prison population, there has
been a flood of them back on the streets. I'm also going to speculate that
many of the mentally ill also have drug dependency issues.

------
Qantourisc
The choice here is (maybe there is a grey-scale here, but I don't see it):
either you accept oppression and forcibly commit them (under certain
conditions), or you value freedom and let them be if they choice to. The only
general consensus seems to be: when they don't break any laws (or endanger
other people).

------
rbcgerard
It's always hard to judge the way people will certainly abuse a new authority
over their fellow man

------
fpgaminer
One of my friends was mentally ill. I had known him for years, but never knew
about the illness. It wasn't until a cataclysmic event which resulted his
suicide that I gained first hand experience with ... the tragedy of these
broken minds.

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.

~~~
raphlinus
Thank you for sharing the story of your friend. It brought tears to my eyes.

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.

------
known
Call 911

------
19eightyfour
To be honest, when I have a lot of money, I want to build housing for homeless
people, but there's a difference. They work for us. There's a product that any
human can do. We have a couple of floors full of cubicles with terminals. And
in exchange for doing X hours of work for Y days per week using this product,
a person gets their own room, 3 meals a day at the canteen, and some kind of
monetary / card / bitcoin allowance they can use in the outside world. The
housing has its own in house security, with monitoring and accountability.
Also we vet and include some sort of community building, personality building,
NGO / social welfare programs to work with people. It's sort of like an 18th
century work house. Without the shame, coercion or slavery aspects.

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.

~~~
hashkb
You have good intentions but need to learn more about how one finds themselves
in chronic homelessness first.

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.

~~~
19eightyfour
I think it's fair to expect something in return. As long as the terms are such
that suit the people, they'll be part of it. These people survive on their
wits and customs of the street. They're not as hopeless as perhaps is made
out. My idea is to redirect their energy and resourcefulness towards something
useful, and add some socialization and boundaries that help them interface
more fruitfully with normal civilization. But importantly, as a first step,
doing useful work in exchange for things they need.

