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How Oregon ensnares mentally ill people charged with low-level crimes (oregonlive.com)
45 points by joveian 22 days ago | hide | past | web | favorite | 28 comments

I’m a psychiatrist, and I worked at Oregon State Hospital.

This article, like most articles about mental health, raises some important issues while somehow managing to get lots of things wrong.

First off, the remodeling of Oregon State Hosital resulted in a net decrease in beds. Another recent project to consolidate most of the inpatient psychiatric beds in the center of Portland also resulted in fewer beds, but let local hospitals divest themselves of inpatient units they never wanted because they lose money. So, there are not many places for people with active and severe mental illness to get inpatient treatment (which is, of course, not the only way to get treatment, but can be a major one for people who are incapable of recognizing they are ill).

Having worked in other states, it is my opinion that the crux of the problem is that there are too few avenues to get people help when they need it but don’t recognize the need. Because it’s so increadibly hard to get people involuntarily hospitalized (which I recognize can be abused), we end up with them being arrested instead. As noted above, involuntary hospitalization can be abused, but when so many mentally ill people go untreated until they are arrested it’s perhaps time to reconsider if things are working as intended. Then, once someone is arrested, evaluated as needing to be restored to competency for trial, and finally gets to the hospital, many of them decline medication. For most of them, it’s implausible that their condition will improve without it. So they have arrived at a point in their life where they don’t know they are ill, have done something to get themselves arrested that’s often related to their symptoms, and continue to decline treatment. I see it as an unintended consequence of such strong protections on individual rights.

Of course those individual rights should be protected, but I would respectfully suggest it’s time to reconsider where the lines are drawn. This movement of the mentally ill from asylums (where they were often mistreated) to jails and prisons has been dubbed “trans-institutionalization” if you want to read more about it.

It is a Big Deal to deny someone their autonomy, no matter which way you slice it. I think we agree on that.

But, respectfully, I think that because it is such a big deal, imprisonment is the proper escalation. It's necessary to maintain a sense of proportion, and we need to avoid - at all costs (and I think that is where we diverge) - the decrement of the right to autonomy. If we make it less of a Big Deal to revoke that right, 'merely' hospitalizing them, we lose our respect for that autonomy.

That’s the tact that Oregon has taken, and I can see the logic in it. But as a doctor I find it more palletable to explicitly try to work in someone’s best interest than to send them to jail/prison. I am obviously biased, but I have seen hundreds of people get well and go on to live lives that they themselves would identify as more rewarding. Deprivation is, and should continue to be a very big deal. But when it becomes necessary, I’d rather that it be focused on the best interest of a person who’s not in a position to recognize their own circumstances.

Clearly it’s a value judgement and there’s no one right answer. It depends on which of two bad options you find least offensive.

> Psychiatry possesses an inherent capacity for abuse that is greater than in other areas of medicine. The diagnosis of mental disease can give the state license to detain persons against their will and insist upon therapy both in the interest of the detainee and in the broader interests of society. In addition, receiving a psychiatric diagnosis can in itself be regarded as oppressive. In a monolithic state, psychiatry can be used to bypass standard legal procedures for establishing guilt or innocence and allow political incarceration without the ordinary odium attaching to such political trials.


Is that "inherent capacity for abuse" overstated?

I'm less afraid of the corrupt psychiatrist than of the one sincerely convinced that people who think like I do are sick.

It is real and relevant, and already accounted for in the concerts about limiting personal liberty. The usual mechanism to address this is to require more than one clinically trained person to agree, which holds them for a few days until it can be heard in court and decided by a judge. This requires it only illness but immediate danger to self or others. This has had the unintended consequence of conflating mental illness with violence. Always trade offs...


> The usual mechanism to address this is to require more than one clinically trained person to agree, which holds them for a few days until it can be heard in court and decided by a judge.

It seems the above would only work (meaning that it would prevent abuse) if:

a) the 'clinically trained persons' affiliate with different political fractions

b) there is no 'federal-level' oversight hammer that can strip them of their credentials for testifying against the wants of the currently ruling political fractions

c) The judiciary system overall is free from 'selective-outrage' ( Which is, unfortunately, some would say, not the case for US, Canada, France, UK, Australia, not even mentioning known oligarch/dictatorships countries out there )

There was also an article recently about how the state kicked a bunch of people out of residential facilities:


It seems like everyone agrees that community services are hugely underfunded. Given that situation, I find it hard to believe that lack of involuntary commitment is much of an issue. How would involuntary commitment help if resources aren't available for voluntary treatment? I also think you are underestimating the abuses of involuntary commitment. Unity was almost shut down due to various issues. Attempted treatments can also cause lifelong issues and there seems to often not be effective treatment available.

The main reason I posted this article is that I wasn't aware of the situation where people who are judged incapable of assisting in their own defense are being given the maximum possible punishment for the category of crime they are accused seemingly without any attempt at considering if that is reasonable without their involvement.

> there are too few avenues to get people help when they need it but don’t recognize the need

Do you mean forced treatment aka involuntary hospitalization?

What are the statistics on cure for this? Does treatment work? If cure rates are not high, is this just long term incarceration without due process that finds one has actually committed a crime?

I'm not an american, and some points seem alien for me. Is it really bad to jail mentally ill homeless man? He is homeless, he is mentally ill, he have nowhere to go, he have no warm and soft bed to sleep, he need to eat, and have no ability to find food. He is forced to break a law to steal a bottle of tea to drink. Probably he is stealing his food to eat. The jail imprisonment can solve the most of these problems for him. Moreover he would get medication, which can make his mental life more comfortable. And it is good for a society: he now gets his dinner legally without need to steal.

I agree, that $1k per day per patient for that is a way too much, and I see this as the problem. But while reading this article I've formed a suspicion that article points to moral unacceptability of imprisonment of mentally ill. It is unacceptable because it is amoral and to hell with all the attempts to reason rationally. Is my suspicion is a right one?

US prisons are more like torture centers than a traditional rehabilitative institution. If the prisoner doesn't behave just right, he could end up locked in a small room 23 hours a day. He could end up assaulted and abused. He could end up being taken advantage of.

In the US we have institutions for the mentally ill and he would be better off there, but it's becoming increasingly more only for the wealthy to use.

> US prisons are more like torture centers than a traditional rehabilitative institution. If the prisoner doesn't behave just right, he could end up locked in a small room 23 hours a day. He could end up assaulted and abused. He could end up being taken advantage of.

Is this really true? This seems to be a popular assessment but every now and then I see first-hand accounts of people who went to jail/prison and my main takeaway from them is that it's simply boring and nothing really happens, and that the average joe is just going to go in, be bored, and get out.

There are definitely big stories/issues that come out every so often but they seem to be the exception rather than the rule.

LA county jails are dangerous especially if you aren’t white. Depending on the unit, your pod will be ran by either a Hispanic or Black gang member who runs the “program”.

I was arrested on a minor misdemeanor and thanks to the magic of corruption, got thrown in jail for 35-days when my plea deal was 0.

I was in jail with convicted murderers, people on murder trial etc. I was handcuffed to a man that was savgely beaten by gang members for a minor offense involving a newspaper.

The process to goto court was insane — including dry runs where you basically sit in a small cold holding room with up to 50 people from 6am to 5pm but are never called to court. In that room, inmates had been murdered and yes they’re cameras now but people cover them up for a fight.

This was my 1st arrest, for a dubious crime. I even called the police for help, was unjustly arrested than put in jail with violent criminals and violent deputies whose behavior has improved since the FBI installed video cameras.


The police and the courts pretty much do whatever they want, regardless of what's actually said. If they say you go to jail for a month, you're going to jail.

Also, in the US, 75 percent of people in jail are back within 3 years. It's not necessarily because people can't "get better." It's also because US society is setup to continually attack people who have gone to jail and send them back. It's the entire reason why the majority of people in jail being minorities is so egregious.

Not an American, so can't tell if you think 35-days custody is a lot or a little for a first offence?

For a 1st offense, minor misdemeanor, 35 days is a LOT.

So either the misdemeanor was not minor, or this guy has something else going on?

Like maybe he's black?

Maybe he's dating the arresting cop's ex? But if this kind of thing were the case, you'd normally see more charges. (And no plea bargains.)

I'd say maybe it was a political thing, but it's not an election year.

Who knows? But 35 days is way outside the mean. The average person would not get that much for a 1st offense on a minor misdemeanor.

Being black does not net you a longer sentence. That's just stupid.

It's well researched that black people get longer sentences than white people for the same crime.


According to your pdf file, 19% longer. So this guy is exaggerating or something.

"19% longer" on average does not mean that each sentence is exactly 19% longer than it otherwise would be.

You were already wrong in your confident assertion once. Perhaps re-examine your priors before continuing?

Inpatient mental health facilities are mainly for the wealthy since deregulation in the Reagan era. That was almost 40 years ago. At this point, you have to be a danger to yourself, at which point they admit you to a hospital for treatment, or a danger to others, at which point they put you in jail. Both of these facilities have become defacto mental health facilities for the poor and lower middle class, I'm sorry to say. This isn't a "becoming" issue, this issue already happened.

> US prisons are more like torture centers

Torture: > the act of inflicting excruciating pain, as punishment or revenge, as a means of getting a confession or information, or for sheer cruelty.


Please stop with the hyperbole and misapplication of defined words. You degrade the actual meaning of the word when used improperly in this context. Also, you state that it's a voluntary action, entirely controlled by the prisoners behavior.

> If the prisoner doesn't behave just right

So - behave if in prison. Seems reasonable.

Contrast what you claim is torture, with actual torture that does go on: https://www.theguardian.com/world/2017/jan/23/lawyer-torture...

I'd take your version of torture any day of the week, because it's actually pretty tame compared to real torture.

Not only is this classic whataboutism, but it ignores the reality of the US prison system being an absolute horrific nightmare for many people. We still use solitary confinement here in the US which is absolutely considered torture in many circumstances.

It's far from hyperbole and far from voluntary, especially when you start considering the needs of the mentally ill with regards to prisons and how they're supposed to behave.

solitary confinement is quite common in Asia. And no, we don't consider that as torture.

Given the psychological effects of extended, externally-imposed isolation, it should be considered a form of mistreatment everywhere.

Many countries and people consider it torture: https://en.wikipedia.org/wiki/Solitary_confinement#Torture

And solitary confinement is one small part in the overall torture scheme perpetrated by US prisons. It's not hyperbole, it's the facts.

> this classic whataboutism

Not in the least, unless you are saying "what about using the actual definition of the word" is a bad thing for people to do.

> Is it really bad to jail mentally ill homeless man?

One point is that should we forcibly imprison someone who has not committed any real crime?

Or even put them in a mental hospital?

In the US at least jails and mental hospitals have a long history of twisted sadistic abuse by extremely well meaning individuals who were convinced they knew what was best for these people.

During the Bush II administration he appointed a Homeless Tsar (who didn't like Bush) who advocated for a program where the hopelessly homeless were put into a decent 1 bedroom apartment, signed up for health care, and given a small monthly stipend. This cost less than these men were costing society showing up at the emergency rooms with frostbite and side effects of diabetes, etc. One controversial aspect was that there were no restrictions on what they spent the money on. They could for example purchase vodka instead of food if that was their desire. Unlike with most homeless shelters, they were left alone and allowed to live their lives as they chose if they wanted that.

This program was very successful and greatly decreased the cost of managing long term homeless persons.

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