
Medicating a Prophet - santaclaus
http://www.nytimes.com/2016/10/02/opinion/sunday/medicating-a-prophet.html
======
knodi123
Fascinating article. Who decides the mission of a psychologist? Is it to
maximize happiness of patients' lives as a whole? Is it to help patients to
reach their full potential as productive members of society? Is it to help
them to conform to societal standards of behavior or belief?

If I wasn't on guard, prepared to devote thought to the question, I'd have
accepted any of those answers - but this article makes it easy to see how
those different goals can be in conflict.

If I had to come up with the best answer I could, I think I'd settle on "A
psychologist's mission should be to prevent a person from actively harming the
physical health of themselves or others, even taking into account reasonable
expectations of future harm based on current activities. And additionally to
help make any adjustments that the patient requests." So, sometimes it's okay
to involuntarily treat, but only if there's a present or soon-to-be present
physical danger. Otherwise, only help them with the things they want fixed.

(Note: I once had a long and coherent conversation with a guy who _knew_ he
was the messiah promised to the jews, descendant of david, future _king of the
world_. It was an unavoidable fact. Him being a young, black presbyterian had
no bearing on the issue. He had lots of evidence, much of it delusional, and
much of his reasoning was based on bad information that he was _literally_
incapable of doubting. But in the end, his delusion was immensely satisfying
to him, and his life was otherwise boring, banal, and from an outside
perspective, depressing as hell. And from what I can tell, as long as he
doesn't travel to Israel and get a jewish girlfriend, the more dangerously
bizarre parts of his prophecies won't begin, so I just decided to wish him
well and let it go.)

~~~
openasocket
> So, sometimes it's okay to involuntarily treat, but only if there's a
> present or soon-to-be present physical danger

If you weren't aware, that is the current standard for involuntary
hospitalization, at least in the US. I believe the phrase is "danger to self
or others."

~~~
bryondowd
Sadly, being on the streets and incapable of caring for oneself isn't
considered a 'danger to self', at least in the eyes of the hospital that
evaluated my former fiancee.

Personally, I think we need to set the bar for involuntary intervention higher
than being an active threat. If someone doesn't have the mental wherewithal to
not lose their coat in the middle of a cold snap, that seems like a clear
indicator to me that they need help and their refusal shouldn't be taken any
more seriously than their delusions.

I may be biased and embittered on this subject.

~~~
sushid
To me, freezing yourself to death seems like a case of 'danger to self' but
I'm neither a lawyer nor a doctor.

But in other situations, the question arises just like in the article. At what
point do you want to dose the individual with a sense of reality? If their
mentally-ill self is content with the life they lead and "curing" them of it
will leave them empty, sad, and hollow (in addition to the side effects of
medication), is the arguably a better option?

If you factor in the fact that the hospital won't be there to help him rehab
back into society, I can see the decision being difficult to make, as the
author mentions.

~~~
ThrustVectoring
I mean, it could be interpreted as a 'danger to self', but choosing that
interpretation loses the hospital money. I'm saddened but not really
surprised.

------
carapace
I once encountered a young man who was reading the Necronomicon, a cheap and
utterly fictional paperback put out to tie-in with the Lovecraft mythos. It's
a prop to make a few bucks, no more real than a plastic Star Trek phaser.

Something about the way he was reading it caught my attention, so I asked him,
"You know that's fake, right?" To my astonishment, he began to protest and
describe how "they dug it up in an archeological site" or something. The
chilling thing was he really seemed into it.

I left thinking, "There's the formation of a psychotic reality, right there in
front of me." Dunno what I could have done about it.

~~~
GuiA
How's this any different from people who spend tens of thousands of dollars
stocking up on food and weapons because they're convinced we're on the brink
of nuclear war, or people who are convinced that Obama is a secret Muslim
terrorist infiltrating America, or people who absolutely believe that the
(Bible/Qu'ran/Old Testament/...) is the word of god, or...

~~~
bpodgursky
> spend tens of thousands of dollars stocking up on food and weapons because
> they're convinced we're on the brink of nuclear war

I mean, I haven't stockpiled anything personally, but honestly that's a pretty
reasonable cost-benefit analysis. The world _is_ perpetually pretty close to
nuclear war, if you treated the risk like any other day to day risk.

(You probably spend more on health and house insurance than they spend on
food, and IMO nuclear war is more likely than a given house catching fire in a
year. The unknowable question of course is whether it will manifest in a way
that your preparations matter)

------
daveguy
> That night 13 years ago, I did hospitalize my patient who thought he was a
> prophet, and he received treatment that he had not consented to. I never
> found out what happened to him. I think about him often; I question my
> decision each time I do.

Regardless of whether she was right to commit the person to treatment -- how
did she not follow up on this? That shouldn't be the end of the article. Why
didn't she follow up? If she thinks about it she was obviously interested on
some level. Was she legally prevented from following up? Shouldn't follow up
be required?

~~~
cestith
You expect a resident called into an ER in the middle of the night to follow
up on the long-term treatment of every patient?

------
xutopia
I'm often bummed out whenever someone tells me about their problems and I talk
to them about solutions or new ways of thinking and they tell me they just
want an ear to speak to.

If I weren't empathic I could just shrug but I see people making big life
choices over ridiculous assumptions and I'm asked to keep my expert advice to
myself.

This article shakes me at my core... perhaps what's best is to be there until
things blow up and then swoop in and save the people from an even worse spot.

~~~
jordanlev
As I've grown older, I've learned that often the best thing is to just listen
to people. Sometimes just letting people vent and share their problems is the
most you can do (and it _is_ helpful to most people to have an outlet, even if
to you it seems like you're not "doing anything" or "solving the problem").

~~~
falcolas
Agreed. And if they're looking for help, they'll usually ask for it.

"What's your opinion?"

"What would you do?"

~~~
cypherpunks01
I agree, though not everyone does this—it depends on the person and the
interaction a lot I think. If I can't tell, I usually just like to ask:

"What do you think you'll do?"

This is often helpful and I sometimes consider it as a listening strategy.

------
pmoriarty
There was and is an anti-psychiatry movement[1] which has a very interesting
history.

[1] - [https://en.wikipedia.org/wiki/Anti-
psychiatry](https://en.wikipedia.org/wiki/Anti-psychiatry)

~~~
tcj_phx
Psychiatry is the only medical specialty to have an active resistance
movement. The problem is that their go-to treatments are palliative, and do
NOT address any of the causes of their patients' conditions.

Robert Whitaker has found the evidence supporting the use of commonly-used
drugs actually shows that psych patients do very poorly when medicated for an
extended period of time [1].

[1] [http://www.madinamerica.com/2016/07/the-case-against-
antipsy...](http://www.madinamerica.com/2016/07/the-case-against-
antipsychotics/)

Before the tranquilizers became available, people had episodes from which they
usually recovered. Now their chronic conditions are 'managed', until they die
20 years earlier than would otherwise be expected.

------
matt_wulfeck
I read the article and can't help but wonder where the family is in these
situations. Why are doctors forced to commit someone against their will? Isn't
that a decision better left to a family member?

More and more we're asking society to take on the role traditionally held by
family members. The author is describing a symptom to a greater issue, which
itself is probably a symptom to some other issue as well. It's symptoms all
the way down.

~~~
John23832
Not to attack you, but that's a little closed minded.

Not everyone has a family structure to depend on. Many times, that's a
contributing factor to the predicament that disturbed person is in.

------
koolba
Another big problem is that if a hospital admits a patient for mental issues,
they'll have to treat their physical ailments as well. Since the patients does
not have any money or insurance, that comes out of the hospitals pocket. So
they have an incentive to cut as many "harmless" people loose as possible.

------
kordless
Every single person who advocates or speaks in a visionary way about a new
belief, cause, or theory is a prophet. Silicon Valley is full of prophets
trying to profit from making their internal view an _external_ view for all of
us.

~~~
mwfunk
I guess I would call those SV people inventors and/or entrepreneurs? Or
visionaries (in the business school sense or the literary sense, not in the
mystical sense)? There are multiple definitions of the word "prophet" and you
have chosen the one where someone just imagines something that doesn't
currently exist, but might or will someday. i.e., a prophet is just someone
who is prophetic in the broadest possible sense of the term.

I think of a prophet (in the context of this article and this thread) as
someone who is convinced that they literally have supernatural insight gifted
to them by some unseen omnipotent being who sits behind the curtain of the
universe pulling the levers.

I'm not inherently scared of someone who thinks that if only they could get
the right product out there, they could make some money (and maybe even make
some people happier in ways that they weren't before). I am inherently scared
of someone who has convinced themselves that some unseen omnipotent being has
a message for the world about who's good and who's evil and what's going to
happen in the future, and everyone who doesn't get on board deserves to have
bad stuff happen to them (in this life or the next).

Although, I guess that person is harmless in isolation- what I'm really scared
of are the people who hear someone like that and decide, "hey this guy clearly
knows what's up, let's just listen to (and do) whatever he has to say, and
stop thinking about all these hard questions about ethics and morality and
life and justice. Even better, we get to act like we know infinitely more than
all those poor bastards who wrestle with that stuff every day!". Anyway,
that's what I think of when I think of a prophet. Someone who claims to have
the answers to the hard questions via magic.

------
pmoriarty
Two much more powerful, deeper, and more interesting articles on the same
subject:

[http://www.newyorker.com/magazine/2011/05/30/god-knows-
where...](http://www.newyorker.com/magazine/2011/05/30/god-knows-where-i-am)

[http://www.columbia.edu/cu/neuwrite/pubs/avivHarpers.pdf](http://www.columbia.edu/cu/neuwrite/pubs/avivHarpers.pdf)

------
Mz
I have said more than once that if Joan of Arc were alive today, she would be
in a psych ward having hervmedsxadjusted instead of ending The Hubdred Years
War and playing handmaiden to the birth of modern France.

I am glad this article is promoting the idea that forcibly treating someone is
not really a means to foster mental health. Good mental health is more than
the absence of obvious abnormality.

------
scythe
>He was a college graduate from a middle-class family. But on Christmas Eve
three decades earlier, the Archangel Michael had come to him in a vision and
demanded that he spread God’s word.

Suppose it's false.

 _Given_ that it's false, are his _actions_ acceptable conduct for a person?
Really what is unacceptable is going without treatment for obvious full-blown
AIDS.

>I run a program for young people experiencing psychosis for the first time.
Every day I confront my impulse to coerce people into care. This spring, one
of our participants, whom I will call Mark, once again went off his
medications. He had been on track to finish his first semester of community
college and was looking for part-time work when his father showed up after
years of absence. Soon he was smoking weed daily with his father, had dropped
out of school and was refusing to take his medications. Over the next few
months he became increasingly psychotic, stopped sleeping and started rhyming
all his sentences. Then the sentences gave way to incoherent word pairings
that psychiatrists call “clanging.” Soon he was nearly mute and rail-thin. But
he still refused medication.

You're lying.

Not to me, and not to Mike, but to yourself and to society. Nobody wants to
help Mike be himself or be happy. That's Mike's job. The modern paradigm of
psychiatry says "take your medications so that you can be happy", but what we
obviously mean is "take your medications so that you can work". Here's the
thing: he'll be just as happy smoking weed and babbling as he is at college.
Or, to be more honest, we have no _good evidence_ that he _won 't_ be.

Here's the thing: how on Earth is Mark supposed to work if nobody cares that
he does? The society around him has stated quite clearly that it isn't worth
going to a bunch of effort to get him to work -- he's not being medicated in
order for him to work -- his work isn't necessary or a duty, _according to
everyone who tells him anything about anything_ \-- yet the actual standard
_being applied_ is "does this guy pass his classes?".

The truth is that that sounds awful. But the deeper truth is that the
psychiatrist and the family and the legal system as a whole have collectively
chosen the non-awful fantasy of "mental health" rather than the awful reality
of "crazy people are useless". And then we wonder why the patient wants to
make the same kind of choice!

~~~
openasocket
> Here's the thing: he'll be just as happy smoking weed and babbling as he is
> at college. Or, to be more honest, we have no good evidence that he won't
> be.

You stopped reading at the smoking weed part. After that, he stopped eating,
sleeping, and talking. What part of that sounds happy or healthy to you?

~~~
scythe
It doesn't really matter.

I mean, sure, it might affect the way this example can be used to make the
point, but, in my experience, the thrust of my argument holds in plenty of
situations anyway. And I'm not sure I agree anyway: happy is a very subjective
judgment.

------
empath75
The only difference between a prophet and a madman is the number of followers
they have.

