I'm a psychiatrist, and there are a few things to consider about this story:
1. The bulk of people in a psychiatric hospital are there voluntarily. They can walk out the door at any time.
2. When a patient is in a hospital involuntarily, their stay is subject to state laws about involuntary hospitalization. This, as far as I know, universally requires 2 independent professional opinions that a patient is actively suicidal, actively homicidal, or overtly incapable of taking care of themselves to the point it puts their health at risk.
3. Psychiatric stays are generally very short (less than 5 days), despite the fact that most medications don't start working that quickly. Stays have become unrealistically short.
4. Despite the general outcry about involuntary hospitalization, most family members of a person with a severe illness will tell you that they struggle to get their loved ones admitted even when the situation gets dire.
5. Again despite the outcry, a number of states have been expanding the liability of psychiatrists for the actions of their patients. For example, if my patient were to hurt themselves or someone else, I can expect years of depositions and lawsuits. This does not justify hospitalizing someone who does not need it, but does speak to a double standard about our role in protecting society.
THIS LIABILITY STILL APPLIES WHEN AN INSURANCE COMPANY TELLS ME THEY ARE GOING TO STOP PAYING FOR HOSPITAL TIME 2 DAYS AFTER SOMEONE TRIED TO HANG THEMSELVES. If I release them, it's on me. If I keep them, they face huge bills even if they have insurance. This sucks.
6. MOST IMPORTANTLY, WITHOUT INVOLUNTARY COMMITMENT MANY PATIENTS GO TO JAIL OR PRISON. I work in correctional settings. The decline in psychiatric beds is strongly correlated with the spike in mentally ill people behind bars. Without an avenue to get them treated, they end up getting arrested for their behavior, when they should have gotten treatment instead.
Firstly, it must be incredibly difficult to work with severely mentally ill populations, so I commend and thank you for taking on that responsibility.
It troubles me, however, to to give a government the capability to detain citizens based on the (forgive the scare quotes) "medical" expertise of a psychiatrist. This has been abused [1] and I find significant issues with the credence given to testimony by psychiatrists in the US court system [2]. The lack of science in ever-shifting diagnosis criteria is saddening, and these diagnoses will mirror the prevailing social and political winds. Within some of our lifetimes, of course, homosexuality was a pathology in the DSM.
I'm not sure of the answer here. We do need a way to keep people who are a threat to themselves and others in a safe place, but psychiatry has been and is such a troubling and far-too non-scientific endeavor, long drawing profit from conclusions far beyond our true capabilities to understand the human mind and behavior. I don't want people in the field with anything other than an attitude utter humility and possibly shame exerting control over others' lives.
It's a neat categorization to say troubling psychiatric practices are in the past - I don't think it's accurate.
An example apart from how Psychiatry profits from inserting itself into the legal system - we have society-wide acceptance of the chemical imbalance theory of depression - still without evidence. Because this model is a billions-of-dollars money pipeline for drug companies, who take the bad PR on the nose, and ...psychiatrists.
I have written much less than I could, but I find almost everything about psychiatry - it's influences from Freud, etc. to be problematic.
I know there's no chance of swaying anybody personally invested in the field towards this viewpoint. It's like telling a start-up founder they aren't actually changing the world for the better : /
You might be surprised. I also find the reach of industry to be very troubling, and there's a clear incentive for profit. Many of us continue to push back, and demand better evidence. The erosion of federal funding for research is a concerning development, as it leaves much of the funding to industry sources, who are motivated by profit.
> we have society-wide acceptance of the chemical imbalance theory of depression - still without evidence. Because this model is a billions-of-dollars money pipeline for drug companies, who take the bad PR on the nose, and ...psychiatrists.
Are you just referring to overuse of antidepressants caused by that theory, or are you suggesting that antidepressants don't work? Because there's good evidence that at least in severe cases of depression, antidepressants do work and are more effective than other therapies alone. [1] Even if we don't really know how they work…
Has anyone started making lots (like tens of thousands) high-resolution, 3D, video (i.e., not still snapshots, but over time and ideally during episodic moments) MRI and CAT scans of diagnosed psychiatric patients, pointed a deep learning system at the scans, and see if patterns can be detected? If the deep learning systems can pick up patterns we didn't notice before, then that could be a valuable empirical tool to add.
The Finnish "Open Dialogue" approach is an interesting alternative. It's more about family and community integrated treatment than residential commitment. Recommended search: https://www.google.com/search?q=finland+open+dialogue
> most family members of a person with a severe illness will tell you that they struggle to get their loved ones admitted even when the situation gets dire
In South-Africa you have to beg private hospitals to admit patients with certain psychiatric conditions. The default is to send patients to public hospitals, and that will likely involve much more restraint and much less care.
My respect goes out to people that keep on trying to deal with these situations with limited resources.
I wonder if there is a way to setup the system so that a corrupt doctor that has lost their way is still mainly incentivized to work for the interests of the patient.
Even in medical situations where patients do not face involuntary confinement, they are mostly left wondering if the doctors are working for them or working to bill them (I guess the outcome based payment schemes address this).
Interesting anecdote. My country has public healthcare but you do have to be registered and present a card for it. I didn't have my card once, and the doctor was preparing me for a test when he read on my appointment sheet that I wasn't covered by public health care for that appointment. So he said don't worry about the tests, they are very expensive and I am pretty sure you are fine.
Did the doctor's incentive to run the test when he thought the government was paying lie in the interest of me, the company who does the tests, or the government who wants a healthy populace?
It's hard to know. But I will be honest and say that as I'm paying for just a fraction of it with my taxes, I actually don't mind and if they are being thorough even for the benefit of some medical company's coffer, at least the country can afford to be thorough.
If it's possible that failure to perform a test which is probably not going to helpful has a large downside for the doctor, and performing it has only got downside for the patient - you'll end up with incentives which clearly dictate excessive testing.
Correction: psychiatric stays are generally very short with private insurance, and months long with state insurance. May vary with the level of corruption in your area.
Does my three day involuntary hold (5150) that became a two week involuntary hold (5250) and then an unspecified (and very probably illegal) wait for an additional 4 days, because "we're waiting for the doctor to release you" count?. (yes, I know, one data point is not an average). I saw that doctor exactly 2 times during that time, for a cumulative total of maybe 3 minutes, who was simply a pusher of the latest (at the time) SNRI. The nurses emphasized it was important to "show compliance" and take their drugs, even though they were wrong and caused serious problems for months.
Why? I apparently offended a psychiatrist when I insisted that escitalopram ("Lexapro") gave me mild/moderate visual disturbances (hallucination). "Lexapro doesn't do that!". Insisting it did, followed quickly with a (probably mildly rude) comment about observation-vs-theory and just-world fallacy only cut the appointment short and started the above stay. The paperwork was sensationalized fiction, with zero basis in reality.
After the first 3 days, the nurses commented every single day about how unusual it was to be allowed (by insurance) such a long stay. Private insurance would never allow the expense, but apparently their scam worked on Medicare.
I never generalize bad behavior into a stereotype. I'll assume your experience has been very different. I'm sure this kind of problem has a lot of variation. My stay was over 10 years ago, and I would like to believe your industry has improved in that time. It might be a good idea to look outside your normal situation with the goal of gaining a broader perspective. It is very hard to regain trust after it has been burned for legitimate reasons. That puts better doctors at an unfair disadvantage, which is unfortunate. This is why it's so important proactively find the "bad apples" and actually fix the situation before bad behavior becomes normalized[1].
Well how about the article in question? It doesn't say a month but the gist of the article is that profit is motivating at least one chain to make patients stay too long. Which is the essence of the point you are responding to.
My wife is an inpatient psychiatrist. She gets a monthly productivity report. Her pay is based on the productivity. In her system she gets more money on the day of admission than for subsequent days. This gives her an economic incentive to get patients out the door. She hasn't yet succumbed to the pressure to release them early but it's foolhardy to think that economic forces don't or can't play a role. There are lots of examples of doctors doing very bad things for profit.
I worked at an inpatient hospital that had monthly productivity reports. My salary was totally independent of them, and I still quit after a few months because I didn't like the implication. I would encourage your wife to do the same. For most of us, that's not why we went to med school.
In Florida we have the Baker Act, which is common knowledge in FL outside even mental healthcare circles, and is a 72 hour involuntary institutionalization for examination.
Right, but that's only for attempted suicide and it doesn't mean they aren't kept AFTER. I was looking for a citation that suggests involuntary stays are shorter than a month on average, saying that there is a minimum of 3 days in some cases doesn't give me an answer to that.
My girlfriend has had three stays at two different UHS hospitals in Phoenix (UHS is the subject of this ars technica article). They tried to keep her indefinitely the first time. The second two times were unnecessary month-long "stabilizations" that did not address the causes behind her presenting symptoms (self medication with alcohol). At the third stay UHS got her addicted to benzos, which stopped working after a month...
I know you're a psychiatrist, and it seems like you practice in a fairly conventional manner. My experience with the mental health system is that the doctors have good intentions, but have been misled by their training. Because my girlfriend's doctors have inverted cause and effect, they haven't been able to help her get her psychosis-provoking self-medication tendencies under control (they think that psychosis -> drug use, or that alcohol/drug use is a separate condition from her psychotic disorder).
For her first stay at UHS, it took a few days of calls for me to figure out the "magic words" for my girlfriend to say to get them to let her out - this was after about 2 weeks of "stabilization" that was really just getting her used to the tranquilizers. Finally someone told me she had to say "against medical advice", and they let her out two days later.
She started to come out of her zyprexa-maintained psychotic coma after about 3 days, then she resumed self-medicating her physiological imbalances. I knew that alcohol wouldn't help, but I couldn't prescribe what she needed, or force her to take it anyways.
She was under a court order for the second two stays at a different UHS facility, so she was powerless to resist the obsolete theories that they used to worsen her condition.
It is now known that psychosis is related to cortisol deficiency. Cortisol is produced in the mitochondria. Therapies which improve the metabolism are indicated for all mental health patients.
The only helpful treatment that my girlfriend received was getting revived by the fire department (benzos amplify opiates, fyi). Her drinking was under control for about two weeks after those two doses of naloxone. Naltrexone (similar to naloxone) is FDA-approved to help people keep their alcohol use under control.
I was able to verify that my theories were basically correct when she lived with me for about two months. But then she went to visit her mother, and made herself psychotic with the street pharmacy again (bad situation with her old not-friends -> alcohol -> meth amphetamine), and she's back to getting "helped" by professionals who don't care about cause-and-effect.
I guess I'm just asking you to consider that anti-psychotics are most psychiatric patients' problem, rather than their solution. Since you work with the criminal justice system, you're in a position to do a lot of good for a lot of people.
This is an appropriate article to comment with the Rosenhan Experiment. From Wikipedia: The study involved the use of healthy associates or "pseudopatients" who briefly feigned auditory hallucinations in an attempt to gain admission to 12 different psychiatric hospitals in five different states in various locations in the United States. All were admitted and diagnosed with psychiatric disorders.
After admission, the pseudopatients acted normally and told staff that they felt fine and had no longer experienced any additional hallucinations. All were forced to admit to having a mental illness and agree to take antipsychotic drugs as a condition of their release. The average time that the patients spent in the hospital was 19 days. All but one were diagnosed with schizophrenia "in remission" before their release. [1]
This article also makes me think Wells Fargo-esque pressure from above is to blame, but won't be heavily punished by the authorities. At least in the WF case two executives had to pay back $75m. [2]
That's an interesting experiment, but what was the expected outcome? The deliberately feigned illness to get in and then reverted to completely normal. That's not a class of patient that is ever expected to show up. How would someone expect those cases to be handled and why?
You'd at the very least expect medical experts to be able to identify non-ill people. That part of the experiment isn't the most damning though, The part where they told hospitals they'd repeat the experiment and then didn't is. Suddenly the hospitals managed to finger many of their patients as pseudopatients when in fact they weren't even part of the experiment.
So yeah, a mental health industry that can't differentiate between sane and insane in either direction scares me.
I once met a mural artist who told me a very memorable story of his peculiar time at the cuckoo's nest, how he got there and how he left. It was the 1960s-70s and all had been reasonably normal in his life, until his attendance at a certain party. Though he was untroubled in the company of recreational drug fiends, he didn't participate, at least not deliberately. However, someone had surreptitiously spiked the punchbowl with LSD. Being a gentle and kind sort of creature, he unwittingly embarked on a profound psychedelic odyssey. Still under the effects of the punch and yet unable to rationalize the situation, he called his sister for help, who persuaded him against his better judgment to check in to a psychiatric hospital. Shortly after, his state of mind returned to normal where he was able to assess the cause, but the talons of the ward took hold and would not let him go. They'd already begun to medicate him heavily with tranquilizers which clouded his mind and dulled his resolve. His pleas for understanding were ignored and he soon realized that he'd become a prisoner. In this situation his only assets were his art and good character. In a sanctioned stupor he devised a plan; he would begin "cheeking" his medicine in the presence of the nurses and spitting it out in their absence. He was permitted art supplies, the results of which quickly earned him respect among the staff. He'd use this to eventually obtain permission to paint outside in the courtyard, where he'd scan every possible vector for a way out. His fear had began to impel him after seeing inmates which were previously articulate and sociable become zombies after what he presumed were lobotomies. He suspected he was on the list for the same. Once he gained the trust of the staff, he finally sprang for freedom. He got it and never returned. He carried on with his art, remaining perfectly sane, innocuous and successful in his trade.
A great example of how for-profit healthcare (or anything else) can fail.
Corporate entities have an obligation to do whatever they can legally get away with in order to maximize profits. They do not have a prerogative to benefit society, or help human beings apart from what they choose to do.
Every country has to decide whether the benefits of privatisation of the various services outweighs the societal costs caused by private entities having different goals.
Public psychiatric institutions suffer from the same problem though, because the salaries of the employees running the institution are dependent upon a consistent occupancy.
Not to anything like the same manner and extent. In almost all public systems the salaries are dependent upon political considerations first and actual demand is a long way down the list - the system tends to be underprovisioned and demand rarely falls unless there is mass exodus from an area.
Not really. Public sector employees aren't as incentivised to maximise profits for their employer as private sector employees are. This ultimately makes some public services superior because the employees have no reason to pretend you are are walking wallet instead of a human being.
There's a difference though- if their boss finds out that they did this, in the private sector they'd be rewarded, and in the public sector they'd be fired.
This is a problem localized to psychiatric care, general healthcare has obligations and quality controls, and it doesn't fail in the ways you describe. The fact that medical practitioners take out enormous malpractice insurance policies proves that there is accountability, at least if you're considered sane enough to press charges.
For psychiatric care specifically, the problem is that the patient has no agency by definition. The patient can not complain about the hospital, because people think he's too crazy to take care of himself.
It's rare to find a psychiatric hospital, public or private, that's not accredited by JCHO. This group has the same standards for general and psychiatric hospitals about patient rights, and due process for any hands-on or involuntary interventions.
Psychiatric patients can, and do, complain. The assumption is that they are making a genuine report until proven otherwise.
And if you want to see examples of how government run healthcare (or anything else) can fail, just look at the history of atrocities of public psychiatric hospitals.
I live in Toronto. I've been to the ER here. We were seen promptly, given the right care, and paid no bill.
The efficiencies gained by not wasting time on unneeded treatments, not having a billing department and not paying million dollar CEO compensations, these outweigh, in my opinion and experience, any gains we might have via privatization.
4 to 8 hour waits are fairly routine from what I've heard (Western Canada anyways). Not advocating privatization, just pointing out that the Canadian system is far from the utopia that many Canadians tend to suggest (when the topic is socialized medicare in an international forum.....when the topic is discussed within Canada, many people's opinions deteriorate significantly.)
Well, the Western provinces are very Conservative and don't want to properly fund their health care system. It saves them money on taxes, at the cost of their health. It's a choice they make.
If you ask me, their governments do this so that they can argue "See? this is broken! We need to privatize!"
Oh, definitely. It's probably it's biggest catch- you have to have a people who want to pay the taxes needed to fund it, knowing that in the long run they'll save money.
But that requires long term thinking, which we're bad at as a species...
This article suggests spending is fairly uniform across provinces, with the west not really standing out as spending less, Alberta being even higher, and I know there are long wait times in Alberta.
So money seems not to be the problem. I'm pro-single-payer, but I also have a very large philosophical problem with the fact that people who would like to choose to spend their discretionary income on extra/better/faster healthcare are not allowed to. If I've worked my ass off my whole life, I don't think I should have to wait in line behind someone who sat on the couch eating chips their whole life. I'm happy to pay his bill, just don't make me wait in line behind him. There should be additional resources for those of us willing to spend additional money.
>Corporate entities have an obligation to do whatever they can legally get away with in order to maximize profits...
I love how people generally agree upon this, but when it comes to specific topics, they seem to have a blind spot for this. For ex. Vaccines and how people seem to blindly believe what ever the authority tells them...
Actually I am just noting the curious juxtaposition of these two statements and how the same persons/community can accept both of them at the same time..
>Corporate entities have an obligation to do whatever they can legally get away with in order to maximize profits...
>There is nothing remotely dubious regarding the enormous push for vaccinations, and we should applaud any measures that mandate the same.
The argument for mandatory vaccines is that herd immunity protects everyone; if you allow a small population of a disease to survive it will mutate and new vaccines will be needed for everyone else.
Wouldn't no vaccines be the most profitable for medical companies since many more people would then require constant treatment?
Ok. But you are still trusting that the concerned vaccines has been tested well by benevolent agents, and produced with 100% concern for the consumers/kids, right? Or you would not be so accepting of the same. Is that correct?
I was asking about this trust. Where does it come from. And how can it exist among people when the same people believe that "Corporate entities have an obligation to do whatever they can legally get away with in order to maximize profits..."
>Wouldn't no vaccines be the most profitable for medical companies since many more people would then require constant treatment?
Well. Think about it. You are a company producing 10 drugs that people get occasionally. Some of them have some kind of outbreak rarely. How will you mange production of these 10 drugs, when you have no idea of what the demand is going to be.
Contrast it with vaccines. That have a constantly growing (possibly at a known rate) demand. Also, it seems that companies are sheielded from vaccine related injuries [1]. So what would you prefer?
>The VICP was created by the National Childhood Vaccine Injury Act. The Act is designed to shield pharmaceutical companies from lawsuits in exchange for their continued efforts to make the vaccinations we need. So, because injured patients can't sue the drug companies, the VICP was created to pay them money damages.
This is one of my greatest fears: that I'll be labelled as insane, then taken away and locked up against my will, and when I try to plead sanity, nobody will believe me. Because they "know" I'm insane.
Make an advanced directive, and speak to your nearest relative.
I'm not sure of the law in the US, but I think you have to pose an active danger to yourself or other people for them to detain you, and they can only hold you for short times.
Abuses do happen (which is why you need to talk to your nearest relative and get and advance directive in place) but they're rare.
Unfortunately, justice is glacial, and the law doesn't protect you in the short term. The devil is in the implementation, and the actors.
You don't have to be a danger to yourself or others. Only one psychiatrist in the ER has to say that they estimate you are. I'm not aware they have any incentive not to hold you, and increase their liability.
Next, you'll hear they can hold you for 72 hours to evaluate you. That's meaningless. They can hold you for as long as they want to. At the end of 72 hours they can decide to commit you, or even easier, they can bully you into admitting yourself voluntarily, implying they'll commit you otherwise. If you stay "voluntarily" and then try to sign out at a later date, they can again bully you by threatening to take you to court.
If they commit you, you get a court hearing a few weeks later. The rules of the hearing couldn't be simpler: the judge does exactly what the psychiatrist recommends, full stop. After that, appeals become increasingly fewer and further between.
If you're being held 'wrongly' (i.e. you disagree with their assessment) you're entirely on your own to find competent advocates. It can be very difficult, and it can take months before you find someone who wants to make anything happen. Last time I was in, it took me 2 months of working the phone every day, until I somehow managed to reach a high-up lawyer with the state board of oversight. And they just happened to be a nice person who sympathized with my situation.
As I said upthread, you really do not want to get committed if you have state insurance. Private insurance will try to shorten your stay. State insurance leaves you at the hands of the institution. Until I found that lawyer (who had me out after another 2 weeks) the doctors were working on transferring me to a long-term state hospital.
Everything you say here is basically what I've observed.
> Unfortunately, justice is glacial, and the law doesn't protect you in the short term.
I got a court order freeing my girlfriend from the first hospital in a day and a half. Then I made the minor mistake of returning to the hospital without a police escort, and they succeeded at sucking her into the system. It's been slow-motion anti-justice ever since.
> Last time I was in, it took me 2 months of working the phone every day, until I somehow managed to reach a high-up lawyer with the state board of oversight. And they just happened to be a nice person who sympathized with my situation.
Thanks for sharing this. My current case is in the court of appeals, and is probably going to take another 3+ months. This is something I can do to hopefully get the treatment providers to stop their palliative treatments more promptly.
In my country you have to be an imminent danger to yourself or others. Even then the police might release you after questioning, because they might not recognize you are delusional or psychotic. In the case you do end up in psych ward, you are free to walk out unless the psychiatrist gets a court order. Also, every time they put someone in restraints, it has to be documented. The worst thing is meds like haldol, that make you a walking zombie, and are hard to recover from and can cause nasty side effects.
My grandma was kept alive an extra 10 days to let her medicare run out in rural Oklahoma. I'm not sure of all the details because it was 15 years ago and I was a teenager, but my dad said medicare stopped paying for some level of care and then they let her die (she was a vegetable from a stroke).
Private prisons profit from recidivism (rather than rehabilitation) just as psychiatric "hospitals" do.
Though at least in a private prison, you know how long your sentence is, it is an objective measure.
When imprisoned in a mental asylum, you don't know how long you will be in there for, because your release is dependent on the subjective whim of those who stand to profit from the continued occupancy.
There are no objective tests to determine whether or not a person is mentally ill, and this further exacerbates the existing conflict of interest.
This is why there needs to be third-party monitoring, with enormous penalties for misconduct. Public or private, there is no way to make sure this isn't happening unless a hostile party is watching everything.
Looking forward to charges of fraud and, where applicable, imprisonment under false pretenses[1], resulting in stiff prison sentences for those responsible.
[1]: The notion that psychiatric hospitals should be able to keep people there against their will is extremely suspect. A possible exception is a patient being convicted in court of an actual crime, and sent there instead of to prison by the legal system. Even then, the very likely possibility that the hospital staff would extend the patients stay indefinitely would necessitate the judge setting some upper bound on how long the patient can be kept against their will.
> The notion that psychiatric hospitals should be able to keep people there against their will is extremely suspect
It is necessary to some extent because of the impact that mental and psychiatric conditions have on the will itself. But some patient-appointed external agent with formal qualifications and the power to balance decisions, even if imperfect, would go a long ways.
Every state does it differently but in California, you can be held involuntarily for up to 3 days just on the judgement of police or a psychiatrist but being held longer than that does require a hearing with a judge and an attorney where the patient, however impaired or not, can plead their case.
Your comment implies the situation is less bad than the article suggests. To someone held under shady practices, you look like one of 'them'. I wouldn't outright deny that person's point of view. Are you sure you are a psychologist?
Do you know the difference between a psychiatrist and a psychologist? Many people don't, but in the context of this conversation it's pretty important.
I assume anyone who works in mental health is familiar with the basics of empathy. Yes, I am familiar with the difference. I believe psychiatry is a subclass of psychology.
1. The bulk of people in a psychiatric hospital are there voluntarily. They can walk out the door at any time.
2. When a patient is in a hospital involuntarily, their stay is subject to state laws about involuntary hospitalization. This, as far as I know, universally requires 2 independent professional opinions that a patient is actively suicidal, actively homicidal, or overtly incapable of taking care of themselves to the point it puts their health at risk.
3. Psychiatric stays are generally very short (less than 5 days), despite the fact that most medications don't start working that quickly. Stays have become unrealistically short.
4. Despite the general outcry about involuntary hospitalization, most family members of a person with a severe illness will tell you that they struggle to get their loved ones admitted even when the situation gets dire.
5. Again despite the outcry, a number of states have been expanding the liability of psychiatrists for the actions of their patients. For example, if my patient were to hurt themselves or someone else, I can expect years of depositions and lawsuits. This does not justify hospitalizing someone who does not need it, but does speak to a double standard about our role in protecting society.
THIS LIABILITY STILL APPLIES WHEN AN INSURANCE COMPANY TELLS ME THEY ARE GOING TO STOP PAYING FOR HOSPITAL TIME 2 DAYS AFTER SOMEONE TRIED TO HANG THEMSELVES. If I release them, it's on me. If I keep them, they face huge bills even if they have insurance. This sucks.
6. MOST IMPORTANTLY, WITHOUT INVOLUNTARY COMMITMENT MANY PATIENTS GO TO JAIL OR PRISON. I work in correctional settings. The decline in psychiatric beds is strongly correlated with the spike in mentally ill people behind bars. Without an avenue to get them treated, they end up getting arrested for their behavior, when they should have gotten treatment instead.