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The man in room 117 – Andrey Shevelyov would rather live on the street than take antipsychotic medication. Should it be his decision to make?
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- Title
- The Man in Room 117
- Published
- Jan 28 2024
- Word count
- 4421 words
No, it shouldn't. Clearly, if they are incapable of making decisions for themselves and are causing an issue in wider society, it shouldn't be left up to the individual. This article makes it clear that often, no how compassionate you treat people, many will often simply refuse help for a variety of reasons and which causes issues for other people (such as the veterans in this story) or society at large.
I get that I'm not being compassionate here, but I am just damn sick of the mentally ill, drug using homeless problem in my area. I'm tired of seeing entire carts, abandoned, spilled over on the sidewalk. Tent cities taking over any ounce of open space, trash, needles and feces strewn about. I'm tired of trying to take my kids to use the bathroom at the public park and it being closed and locked permanently because homeless have been using it to sleep in or use drugs in or what have you. I'm tired of trying to use the bathroom at the grocery store with my kids, only to have drug users loitering about inside, while the stalls are absolutely trashed, strewn with feces and basic necessities (such as toilet paper) being unavailable, because the dispenser was broken and the toilet paper stolen.
I did have compassion and empathy at one time, but it's been smothered, replaced by resentment towards the homeless. I'm sure I'll get some blowback for this post, but I'm just sick of it. I don't know what the solution is. I've voted for people for the past 10 years who vow to give the homeless homes, stop policing them, stop harassing them and let them live in peace, but the problem has only gotten worse and I think it's time for a different approach, this isn't working.
I think the examples you gave are for sure not okay things that should just be accepted, don't get me wrong.
But the point at which you're saying you just resent the homeless, specifically the mentally ill, I don't think there's much room for any constructive conversation. You've written off an entire group, specifically with illnesses out of their control that they likely struggle for access to support to (at least where I'm from). You can have the issues you have and want to enact change without doing that; don't lose the human in it all it's sorta gross.
Perhaps there isn't much room for growth, but as a person who was previous empathetic to their struggles, my empathy has turned and congealed with all the frustrations in dealing with them as a group. It directly effects my quality of life when I cannot take my children to a bathroom and that is a direct result of drug users causing it to close or (literally) shitting it up. I can't take my kids to the library, because homeless drug users have been smoking meth in the bathrooms and caused the entire place to close down for scrubbing as another example.
Maybe they're just petty white guy problems, but I'm frustrated with the state of things. I'm empathetic towards those who are unable to seek help, but frustrated and angry with those who outright refuse it out of hand. They are clearly unable to take care of themselves so we must forcibly take care of them.
My three year old often wants to run out into the street, eat candy at all hours or throw rocks at their sibling. When I correct them, they often get mad and tell me they don't like me or they'll hit me or whatever. Since they're refusing help in harming themself and others, should I just let them be and allow them to run into the street, throw rocks at their sibling or at my windows and just say, "Well, they can make their own decisions, I guess." No one would say that. So why, when people are so violently mentally ill must we try and take this high road and pretend they can take care of themselves?
I'm not saying we should lock them up in inhumane conditions, I'm all for the social state and I am more than happy to pay my fair share of taxes and then some (I've voted for every tax increase to provide social services that I've been able to in the past 22 years), especially if people can get the care and help they need, but when they refuse and they're clearly a menace, their opinion ought not be taken into consideration for the benefit of the rest of us that live in this society.
How are you able to distinguish between the two groups, because it seems like you are using a subjective lens to determine who is refusing services without interfacing with every homeless person you come across. Who is refusing services and how do you know that? You keep pressing on this "They're refusing" rhetoric, but have you ever considered that the homeless population is growing faster than it can be helped? You say you've voted to help them for 22 years, that means you're older than me. I've been voting for 17 years and the homelessness issues of the US have skyrocketed in that time. Not only have they skyrocketed, but I'm only aware of little half measures of help we've passed for our homeless population, all of which are a husk of their intended plan, cut down by negotiation with politicians that see the homeless as a political tool for their advantage. Without any extra contextualization, your argument almost sounds like someone saying "I don't get it, I put a quart of oil in my car and all the lights on the dashboard stayed on, so obviously this can't be fixed."
I also wanted to draw attention to your use of past empathy as a precursor to justify your lack of empathy now. This is commonly used by people to justify their change in stance, as if previously being empathetic gives them free reign to withhold empathy. Your lack of empathy now is no less abrasive because of your empathy in the past unless you can explain to the listener why you no longer have empathy in a tangible way.
After considering your comment, I realized something else. I know that, in many situations, we have to center our own experience as the most important one, and I don't know that I can definitively say this isn't one of those situations. But I think it may be worth looking inward at your centering of yourself and your children in some of these situations, because the way you're talking about these people make it seem like they enjoy being unhoused. Like they relish shooting up in a public bathroom or sleeping in a park. Rarely is that ever true, it's just easier than standing in line for 3 hours at the shelter or being denied or rejected again. We all know what rejection feels like, I wonder how we'd feel if we had nothing, people looked at us out of the corner of their eye, AND we were repeatedly rejected when we asked for help. I wonder what the toll is on a human that experiences that.
Fair point on your first paragraph. I'm not claiming to know what will fix this nor the rate of refusal of services other than from a partisan source. My experience is anecdotal.
As for my lack of empathy, I can elaborate more than I already have and it primarily concerns my kids:
My use of pubic spaces, including libraries, bathrooms and public transport has been cut off or limited due to safety concerns surrounding the mentally ill/drug using population.
I can no longer go to the nearby park, for instance. When my children are playing, not only are they dodging trash and discarded paraphernalia, but when I encourage them to drink plenty of water because they are playing, I can no longer take them to the bathroom and instead have to pack them back into the car or the bike trailer and get them home and hope they can hold it on the way. Why? Because the bathrooms are closed indefinitely due to the homeless.
When my child needs to poop and I take them to the bathroom at the grocery store, I walk in and there's homeless milling about in the restroom itself, looking for veins. If my child does then use the toilet, there is no longer toilet paper, because the dispenser has been destroyed and the toilet paper stolen. When I complain to management, they tell me they clean and restock the bathrooms hourly, but due to the homeless, they're destroyed near instantly.
When I want to ride the local light rail to go somewhere with my kids, again I'm dodging drug paraphernalia, as well as people openly peeing in the stairwell and elevator. Once this is bypassed, I'm on the train with my kids and a person gets on and then begins opening smoking meth on the train, something I'm unwilling to expose myself or my children to.
I would like to go the library with my kids, but now are they often overrun with homeless, openly browsing pornography on the public computers, but the library can often end up closed completely due to drug residue in the ventilation system. This usually ends up with the library closed for an extended period of time.
So yeah, I'm frustrated and annoyed. I've lived in Colorado my entire 40 years, I've lived various spots of Denver, including downtown for the last 20 and while it's always been an issue, it was never this bad. I could use all those services previously described without an issue and while it was less of a problem when I was a childless adult and could be more easily forgiven or ignored, now that I have children in tow 100% of the time, it's become a safety issue, as well as denying my family of the public good we so diligently pay our taxes towards.
Keep in mind, this is only stuff that I've experienced. This doesn't include my friends and family who have been robbed, burgled or otherwise had their own untoward experiences with the homeless population.
So yes, my heart has hardened.
Come on now.
So you choose to blame the people with difficult to treat illnesses, who struggle to access services that may not exist, but not the fucking politicians and citizens responsible for defunding those treatment options?
Yes, I do, because that's what this entire thread is about and not a Strawman about the system having failed them.
We can argue all day about how the system sucks (it does), but this is a thread about forcing people into treatment when it is available and they don't want it. The question of the thread is, Should we? My response is: yes.
My disagreement with you is over culpability and entitlement.
Your stance implies that you have concluded the mentally ill people you encounter are morally amd socially responsible for their plight and the things they do. T is understandable, especially in America, why someone not so afflicted would hold that view. It is not, however, reasonable along a paychological, social, or spiritual axis to hold these folks blameworthy.
You also imply you and your children are entitled to a community free from mentally ill, and that your entitlement extends even to removing those folks right to liberty. This is a strong tenet, based in calvinism, that persists today, but does not seem to me to be any kind of just. And, there are arguments that your privilege today was enabled partly on the backs of these folks suffering.
My final point is a question-if we treat these people against their wishes at your request, what responsibility will you take for the outcome?
I feel like you are finding things there that they didnt write. They mainly wrote that they want public spaces to be safe for them and their children. They are talking about violent/destructive people, which I am sure they dont think all mentally ill people are.
I don't quite see how do you imagine "treating" someone without a home, addicted to substance use would look like.
Normally one would expect the first part to be solved by housing and the second part by giving them something more interesting to do or have. Like dignity and purpose.
That's exactly what the politicians refuse to give.
Or do you propose concentration camps?
Obviously this does not apply to heavy psychiatric cases with unfixable defects. Those just need to be taken care of by other people indefinitely.
I left a longer comment elsewhere on the thread, but for many people with addiction or mental illness, they require inpatient services and intensive therapy to have a hope of establishing healthy thinking and the ability to self care. We need more housing, yes, for people who are ready and able to self care with our without outpatient support.
That is for people who want help. When they don't want help I think their agency should be respected, up to the point where they present a hazard.
So concentration camps, no, but state funded impatient services and a network of halfway houses? Yes.
I believe we agree. I just did not go into the means and only outlined the general philosophy. Which is not universally accepted. A lot of people still believe regular beatings will perform well enough. Judging from the policy, well over 50% in US and slightly below in EU.
I think partly the issue is difficult to discuss because there are several significant causes/contributors to homelessness. If one person makes a statement about homelessness with one cause in mind, a reply could completely disagree with another cause in mind, and they continue to talk past each other.
I don't think you can really meaningfully discuss homelessness without laying out the main causes, and specifically defining the cause you are talking about. Even though this article is about a specific case, and this one particular cause, I think folks in this thread are still thinking of different things on their replies to each other.
Anyway, thanks for the reply; have a great day!
Do you mean the voting isn't working or the giving them homes and ceasing harassment isn't working? Because I don't think anyone has actually done much of the latter.
In my State and City (Denver, Colorado), we've tried these things. We still do have laws on the books that target the homeless, but by and large, things have improved for them at the will of the voters. We're currently in the process of giving them places to live, so we'll see how that pans out and there are lots of spaces for it, so I'm open to trying. But all the other stuff we've tried seems to be failing.
Since you're a resident and thus more of an expert than the rest of us on how Denver/Colorado has instituted plans to help the homeless, give us some examples of assistance that is in place and failing to help.
Denver has been building housing, as well as providing services for homelessness at an increased rate over the last 4 years. The city provides shelters, as well as other assistance throughout the year, here's a link to what the city provides
https://www.denvergov.org/Community/Housing/Housing-Homelessness-Guide
That said, in spite of our services growing and the rate of spend increasing by millions upon millions year over year since 2020, our homelessness rate continues to grow. Not only because of migrants, but the majority of the unhoused are from Colorado
https://coloradosun.com/2023/12/22/denver-homeless-by-the-numbers/
I appreciate the links, it seems like things landed about where I expected them. Denver is increasing funding for homeless house, but that money is also going towards affordable housing, which aren't quite the same thing, but obviously they're connected. But, despite the funding and efforts, the population is rising faster than they can help. I am always struck in these situations that we tend to treat the symptom and not the cause of our societal problems. I'm not sure I could articulate a solution that's more effective, just something I notice regularly.
It seems the real problem is we expect healthy but poor individuals to suffer to such a degree that helping homeless people too much starts to break the illusion that suffering to survive is necessary. The real solution then would be raising the minimum standard of living. If you're a citizen you should never go hungry, should have clean water, have housing, healthcare, internet access, and safety.
Steal from the greedy and give to the needy.
Except for literally providing people with guaranteed housing (which has pretty much never actually happened anywhere in the US), none of that stuff was supposed to solve the problems associated with widespread vagrancy. All that stuff is literally just the bare minimum level of humanity you can provide to an individual. And “something different”? Pardon me but I find it a bit disturbing that you describe simply not hassling people for being homeless as some kind of failed thing that we need to reconsider. Like what could that possibly even mean?
There's no good answer. No right one. The history of the subject is littered with abuse, government overreach, insensitivity, police brutality, and the casual callous indifference of the public at large.
We have laws about "behavior." Things like violence, stalking, vandalism, and so on. Of course those laws should be enforced. The complicating factor is doing so requires police, which have established an exceptionally clear pattern of taking any excuse to brutalize and kill those they interact with. Anytime a cop encounters you, there is a non zero chance they will assault you, possibly even to the point of your death.
This risk is higher for those who aren't "normal". Who have mental issues. So anyone who says they're in favor of forcing the mentally ill into treatment is basically saying "if they die at a cop's hands, they die."
Of course people who are in favor of police enforcement of treatment will be outraged at my statement, insist that's not their intention; but it is what happens to the mentally ill.
Again, there are laws. Even a mentally ill person cannot be allowed to rampage violently about. If this means they're at risk for death due to drawing police interaction down upon themselves ... there's no way around that. But someone who's acting out must be dealt with. This question is about people some are assuming (with evidence or not) will act out.
Governments have a history of abusing the "right to commit". People who are innocent, who have no actual mental illness, have been forcibly committed. And the facilities that existed, that still exist around the world, do not have anything approaching a rosy track record of humane and civilized treatment.
Who gets hired to work in such a facility? We like to think it's a caring, trained, medical professional. A storybook doctor, a nurse you'd write kind poetry about; someone who cares more than us, who does more than us, who's filled with generous kindness and endless compassion.
No, that's not the reality. Sure there are some doctors, some actual nurses. And even some who are kind, who are patient, who do have compassion. But even then, they become jaded, or corrupted, or tired. Few can last years, even a career, without starting to slide toward the negative ends of those scales.
And the bulk of the personnel staffing such facilities are low-trained, which means most folks can more or less qualify. Since the jobs aren't highly paid, and are high stress, the people who take them are prone (either initially at the onset, or over time as the job wears on them) to sliding away from humane treatment. And becoming more likely to be callous, and brutal, even hostile to the patients. Which leads to them treating the patients like animals.
And some of those "patients" are innocent and mentally healthy, but trapped. Caught in the system.
It's such an innocuous phrase. "Caught in the system." Makes it sound like something routine. Something calm and ordinary. Except for the people caught in the system. Who are trapped, imprisoned. Who no one's listening to. Who no one cares about.
Which is the real point of this whole question. Paraphrased, "these (mentally ill) people bother us (ordinary citizens comprising society); is it moral for us to put them out of sight and thus out of mind?" That's the actual question. So-called "normal" citizens want to not be bothered by all this. They don't want to think about it, they don't want to deal with it.
Then you add the mentally ill into it, who often can turn homeless when they can't retain work or maintain relationships with friends and family (who will do the same as everyone else; want it out of sight and mind). These folks are the "poster boys and girls" for homelessness. A lot of people don't care about homelessness, so long as the homeless have the decency to do it away from polite society. "Go be poor somewhere else pauper. Go out into the woods and die. Don't sit on my sidewalks, camp on my street corners. Just knock that shit off and be poor away from me, thank you very much."
The same goes for the mentally ill. They don't really care. They just want the schizos and voice-hearers and MPDs and everyone else who can't "be normal" to either knock that shit off, or do it away from them. If the schizos wanted to live away from the cities, in the woods, and never come out, they (the "normals") would be just fine with that.
It's that the mentally ill are among us which bothers them. That's what they actually care about. They want everyone around them to be "normal". They hear about these drugs, and think "oh, perfect; magic pill magically makes the problem go away. Let's get some of that shit in here."
Which brings us to rights of a human. Again, acting out, being violent, that sort of thing; that cannot be tolerated. Even if the cause is mental illness. Everyone has a right to conduct their lives as they see fit, so long as they don't bother someone. Hitting others (and similar behavior that's actually criminal) is bothering someone. There are laws, for a reason, and they should be enforced.
Is it sad, that someone keeps acting out and engaging in criminal behavior because they're mentally ill? Yes, of course. There's nothing good or pleasant about it. But society has laws, and society needs its laws enforced, for a reason. It's the contract we all buy into that allows us to live together in a "civilized" fashion, rather than as a collection of constantly warring factional groups.
But just because someone is "normal" when you medicate them is not a reason to forcibly medicate them. Who decides "normal?"
That's the other really big question people like to skip over. They like to act as if "normal" is this ordinary thing we've all agreed upon. That we all know normal, will all agree on what normal is. That normal is just this magical state that's natural and inevitable.
Except normal would have to be decided by people. And people abuse power. People become lazy, become corrupted, become jaded, and develop agendas and biases. We're back to the history of mental treatment facilities, and how they've been abused. And how they're centers for abuse. We think "well, obviously we'd have doctors make the determination."
Doctors who'd work for the city, the county, the state, the country. Doctors who work with cops, with prosecutors. Who are on the government payroll.
If you're the mayor (or city councilperson, a governor, a senator, a rep, a president, a federal department head), and you don't particularly care either way -- which is to say, you're not a heartless asshole hellbent on being sadistic, but neither are you a bleeding heart liberal determined to let every free spirit fly unencumbered -- who do you hire to be those doctors? The ones who your citizens are mad at for not committing people, or the ones who lock "problems" up? The ones who argue with you and refuse to commit folks, or the ones who are agreeable and willing to do as you ask?
And I'm proposing a mayor who's average. What about the evil mayors, evil governors, evil presidents? Look at Florida, with a decidedly evil, greedy, callous, and self-centered governor? Do you want that asshole having the power to appoint people who can sign a paper that says you're insane and need to be locked up? Do you really think he wouldn't be abusing that power you want to give him, right now? Who would he have locked up in the past couple of years? You're willing to let that guy pick who signs the commitment papers?
Papers cops will enforce, and while doing so will beat you and your family for objecting, who'll ignore your protestations of a frame and a mistake? Protestations the actual mentally ill would make the same as an innocent person is? Protestations they hear every day?
Protestations that will sometimes be printed posthumously when you or someone like you dies in custody? Who is beaten into a coma, or loses a limb, due to injuries the cops or facility attendants inflict upon you? Who is overdosed into brain damage, or put into hormonal/biochemical withdrawal due to being forcibly medicated by drugs that are entirely inappropriate since you're not mentally deficient?
It will happen. If we pass laws, or make it the ordinary practice, to return to forcibly committing people "someone" designates as mentally ill ... it will be abused. It was before, and that's why it went away. Bring it back, it'll resume happening again. And that doesn't even touch on hot button abuses like sexual assault, which also happened and would resume happening.
You give people power, they abuse it. A certain amount of power has to be given to the government for government to function. But people don't stop to think about that. They don't stop to think about who would be enforcing something like "forcibly medicating the mentally ill." It's not a rosy scenario, one filled with genuine, honest, caring people.
It'll be filled with the same people that are busy screwing the rest of life up. Greedy people. Callous people. Indifferent people? Calculating and cunning people with plots and plans. Someone in your (city, county, state, whatever) starts becoming a problem? Get them committed, problem solved. The laws remove their rights once they're in; they'd have an uphill struggle to get out once they're in.
Sure rich prominent people can fend that shit off. They have bodyguards and staff, they have competent lawyers with access to funds to work with. But "normal" citizens? Who struggle to cover rent and keep food on the table? Who won't be front page news if they're scooped up? Who would lose years of their lives, even if nothing permanently disabling happened to them in those facilities, while someone who cared about them from outside the facility fought to free them?
No. There are no good answers, but forced incarceration is a very bad one because humans are the problem. It's sad and disappointing that some of us are mentally ill. Maybe one day we can fix such things, but that's a different conversation and topic. But injecting them with drugs so they're out of sight and out of mind is not an answer in the meantime.
If these people are such a problem, then kill them. Oh, that's too harsh? That's too far? Maybe they aren't such a problem then. If their "crime" of being "not normal" isn't worth death, maybe them just being unwilling (for whatever mental 'reason' they've come up with inside their minds) to "cooperate" with "normal society" isn't really as bad as people who want the problem "fixed" are making out.
What most people want is out of sight so it's out of their mind. Which is how we get to where some doctor or other appointed board/person is signing away people's rights with impunity.
I want to highlight this.
We're not going to get storybook facilities filled with saints. Working with society's most difficult people exacts an emotional cost.
I think we struggle to make progress on this because, like you said, there are no good solutions, and—this is what I think—we keep rejecting meh-to-bad solutions hoping for a perfect one, so now we have a worse-than-bad, absolutely horrible situation where the mentally ill are allowed to rot on the streets with necrotizing wounds and freely injecting themselves with an endless, easy supply of drugs.
I think an interesting area to examine is law enforcement. People often cite high domestic abuse rates among law enforcement officers (LEOs) as evidence that LEOs are inherently bad people. But LEOs deal with an average of 30.90 suicides over their career and experience high PTSD rates. Most people struggle to process seeing even a single suicide, let alone 30–31.
Another emotionally difficult workplace is the slaughterhouse and animal factories. There are many reports of workers treating animals cruelly and inhumanely. I don't believe it's in their inherent nature to be cruel: their workplaces shape them as such.
We're not going to find enough saints to staff all the mental healthcare facilities we need. And even if we do, they're going to be meat grinders that's going to suck in well-meaning people, chew them up, and spit them out.
It seems one aspect we could get an at least "pretty good" solution to would be making sure as few people as possible slide downwards to the point of being unemployable and homeless. Making our fully functional individuals happy, comfortable, fed and securely housed. Not that we should ignore the unfixably mentally ill. But let's at least get the relatively easy part right.
What's the alternative? Living on the street? Putting them in facilities where they can make life worse for other people in the facility while they slowly whither?
We're talking about problems that have serious adverse affects on everyone around them. Your rights end where mine begin. I hate dealing with mentally ill people that refuse treatment and become incredibly destructive to everyone they've ever known and loved. This absolutely creates generational trauma. Should we let mentally incompetent seniors with Alzheimers make their own decisions?
The whole point of compulsory psychiatric care is to make them stable enough to improve lives. Are you seriously telling me that it's better to let someone take tranq and rot? Are we really okay with letting people make that choice? I'm in favor of medically assisted suicide and extensive personal freedom, but it's disgusting to me that so many have decided we're okay with people slowly, painfully, publicly killing themselves in a way that harms communities.
Agreed.
The worst facilities are better than what's going on around Kensington right now. Abuse, murder, rape, death and more are already happening on the streets. The Xylazine is literally rotting their flesh. A facility is simply not going to compare in terms of abuse, trauma, or death.
I'm a recovering heroin addict. Thank God my loved ones forced me to get help multiple times until it stuck. And I don't have any chronic mental health issues like schizophrenia.
What we are doing now is not compassionate or respectful. It's not good for the people who are homeless and sick, it's not good for the neighborhoods they're destroying, it's not good for the kids who can't go anywhere near the area, etc. It's worse than any facility Ron Desantis himself could dream up for the homeless. Nevermind the fact that it's funding cartels and other organized crime. The damage done by cartels will last a century if it stops today. By allowing them to profit we are funding human trafficking and other horrific human rights violations. We are also allowing them to ruin their own countries.
Get people off the streets and on their meds whether they want it or not. After some treatment, many of these people will be grateful that they were given the chance to get away from the situation. They aren't thinking clearly enough to make those decisions right now.
Many other countries don't have this problem so we should be asking why we do.
Hey, thanks. You've helped give me some more perspective.
Bodily autonomy is a fundamental human right. People who have the capacity to make a decision should be allowed to make "the wrong" decision. There are several cases in England of people with severe mental illness (such as schizophrenia) who needed eg a leg amputation. They declined. The treating doctors then make a best interests decision, and then go to court to see what the judge says. These are always on a case by case basis, but if someone has capacity (they can retain the information, they can weigh it up, they can make a choice) the courts may well say it's that person's right to decline medical treatment, even if it means the person is going to die.
Compare these two:
https://www.bailii.org/ew/cases/EWCOP/2014/342.html
https://www.bailii.org/ew/cases/EWHC/Fam/2018/3367.html
In this case you have someone who has been subjected to violence from the people supposed to care and treat him. People experience restraint as violence. People die because they've been restrained. Women in particular are subjected to sexual violence from other patients or staff. People, like this man, would prefer to live on the streets than to subject themselves to more violence. These discussions are often framed in terms of "but who wouldn't prefer to live in hospital for two years than live on the street?" -- I know plenty of people who would go to hospital, but who refuse to go to a particular hospital, because of their experiences of being harmed by care.
Part of the answer seems fairly clear: improve the quality and safety and accessibility of services. Recognise that schizophrenia is a devastating illness that requires a complicated bio-psycho-social approach. Remember the human who is suffering.
Once you've done that you can talk about use of coercion and use of forced treatment. The US is pretty awful in terms of MH treatment, but lack of coercion can work. See eg the Trieste Model. https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(21)00252-2/fulltext
Where do we draw a line? If a mentally ill person has the reasoning capacity of a child, why do we treat them as though they're an adult when it comes to decision making? My kids hate shots and if given the choice, they would never get another vaccine in their life; however, I am their parent and I have to make choices about what is both best for them and best for society as a whole, as I am raising what will (hopefully) be two independent, autonomous people. My children can make plenty of decisions currently at 3 and 6, but many of them are absolutely "wrong" decisions.
When a mentally ill person becomes violent or is making choices that actively harm the community they exist in or is even making choices and causing self-harm, when do we get to say enough is enough and you can no longer make your own choices? We're not discussing access here; the person in the article has access and has had many people reach out to provide access, as well as a support system, but this person does not want any of this, so where do we go from there? Access is available and plentiful, so what do we do now when people don't want it?
I get that this is a slippery slope, especially as it comes to a woman's right to bodily autonomy and bureaucracy can decide what makes a person "sane" and able to make their own decisions. I don't think I'm capable enough to make a reasonable decision here regarding those with severe mental illness, but from what I've seen in my own community, what we're doing isn't working when it comes to letting people decide for themselves and it's impacting the rest of the people that reside here.
When it comes to psychotropic medications I can speak to what happens currently- I've seen folks court mandated to take their meds due to being a danger to themselves or others while being considered incompetent to make their own decisions. This usually results in them improving, doing better and being re-granted the ability to make their own medication choices. What happens next varies - some maintain their medication, some intend to but something happens whether being arrested, not being able to afford medications, or just forgetting to take them as anyone does, and some quit immediately. Sometimes they can be caught in a safety net, but particularly when people experience psychosis, paranoia, delusions and hallucinations they can become so quickly disconnected from reality and unwilling to take medications that would re-connect them.
I do want to note, we always assume that someone's psychosis is negative, and I think that's mostly what we hear about because it causes the most distress, but I worked with a client who said God and the Angels talked to him. He described a whole plan that God had for all the peoples of Earth to migrate to the Holy Land, etc. He didn't want to take meds because they made him impure and God wouldn't speak to him anymore. You can't reason that away and he wasn't quite a risk to himself and he didn't perceive that when he was medicated that things were better, because he wasn't speaking to God anymore.
He was not particularly dangerous, but couldn't maintain employment or housing on his own. He's someone that would benefit from being housed and having his basic needs met as it's vastly cheaper than hospitalizations and such. The general issue is that our options are lock someone up in prison, lock someone up in a mental hospital and provide complex community services. The first is expensive and cruel, the second while also expensive, we lack enough spaces and thus isn't sustainable long term without becoming cruel and the third is messy and complicated. Community based services also feel like an "extra" compared to the "necessary" prisons and hospitals and thus even though they're cheaper they rarely feel like good investments to people who only look at the $.
Thank you for relating your experience.
Yes, it is absolutely very easy to focus on the negative. I have a mentally ill person who lives in my neighborhood who I occasionally talk to and he's perfectly harmless and just wants to talk on occasion, which I'm happy to oblige.
I understand about the medication, as I've taken my own for mental health issues in the past for a number of years and was always worried about induced psychosis from forgetting it or being unable to get it from the pharmacy for whatever reason.
Perhaps I'm just in a negative headspace today. It doesn't absolve my frustrations, but it does make me much less forgiving of the things I experience on a daily basis, so I apologize if I've offended. I'm very frustrated with the state of things these days.
I'm not offended at all. I really get that frustration. It's hard not feeling safe. It's, well, scary. And it's frustrating when things don't get better, even if we know the systemic reasons why.
I think it's ok to understand that the current status quo isn't safe for either the homeless folks nor for the housed people trying to go about their day. We just need better options for handling the problem, and right now there's not a lot of will to spend money on it, not enough money at least. So everyone suffers for it.
I have a neighbor who lives across the street from me, and he's got the mental capabilities of a 2 year old, and has for the last 48 years. No one treats him like he's an adult. He has a live-in caregiver who walks around the neighborhood with him and points out the airplanes that are going by overhead so he can roughly point towards them and say "Plane!" His needs are addressed, but no one thinks he can safely have much self-determination.
The homeless people you see are not like that. Some of them may have mental illness, and some of them have made bad choices in life, but you're greatly exaggerating their incapability in the face of them being disruptive and making choices you'd prefer they not make.
Perhaps not, but people are often quite capable of making rational decisions as they pertain to irrational habits.
Someone seeking heroin can make a rational decision, "if I steal x from this person, then I can get more heroin.", but the decision isn't rooted rationally, as they are addicted to a thing that causes them to make such decisions.
Similarly the schizophrenic might make the rational choice, "if I kill this person, then the voices will stop". Again, totally rational decision based in faulty logic.
I have two friends, now recovered heroin addicts. We've been friends since we were in elementary school and yet, I saw them make the strangest decisions to feed their addictions. I had a similar experience with two family members that were alcoholics.
I don't understand how you can read my post and respond with this. I carefully described the fact that mental capacity involves the ability to retain information, to weigh up information, and to form a decision.
No, this person has had fucking terrible care. We very much are talking about access here. He may well engage with treatment if it was provided via an assertive outreach team or some other community treatment team. He may well tolerate a hospital so long as the hospital isn't using violence to force him to take his meds.
And that's the point: we already tried violence. It didn't work, which is why he's in the situation he's in. You're saying we just need to do more violence to this person, and surely it'll work this time.
I was not able to read the article in full as I am not a NYT subscriber. Does it say he refused medication “under the throes of mental illness”? Antipsychotic drugs can have pretty profound side effects, and a lot of people with psychosis will make that choice in a lucid state.
Edit: I found the archive link posted in this thread. I think this is important to consider:
Gift Link: The Man in Room 117
The topics in the comments here have strayed, I think, from the opening premise of the article. Specifically
And I think the only right answer to this is, it depends. Homelessness is a complex issue; not all homeless people are homeless for the same reasons, and any solution to the problem requires multiple approaches to meet each situation.
Some people are homeless because they can't afford a place to live, have run into hard times, are structurally disadvantaged, or are otherwise in need of services that could get them back up and on their feet, so to speak. Many of these folks aren't what is conjured, at least emotionally, when we talk about the homeless epidemic facing many large cities, especially in the western states. These are folks who, with some assistance, can sustain the normal self-care routine of modern society and who want to do so. Obviously, we don't do enough to help folks in this regard.
There are other people who are homeless due to addiction. Many of these folks will reject any social services that come with requirements of treatment for their drug use. Sometimes, this means avoiding shelters that monitor for drug use, but sometimes, shelters are avoided because they can themselves be dangerous. Many, many years ago, I was a volunteer court advocate for children in foster care. I performed home inspections, wrote reports for the court, conducted fact-finding investigations, and advocated for the best interests of the children. I often worked with parents who were addicts. Some of them responded well to offers of assistance, while others couldn't kick their addiction without mandated services. Many of the latter were homeless more than once during the course of their case.
Many cities like Portland cited Portugal as an example of a country that curbed their homeless and drug use challenges through decriminalization. However, what many neglected to note is that Portugal didn't abandon compulsory services for drug users. While they removed prison time, they created a unique system of incentives to seek help and disincentives to continue using. Many drug users do need some sort of disincentive to stop using. I know this from supporting family members who have struggled with addiction and from my volunteer social work.
Gift Link: From Portugal to Portland-Oregon decriminalized all drugs, and overdoses have surged.
Then there are folks, like in the article, who suffer from debilitating mental illnesses. And it becomes more difficult. Should services exist for them to get help? Yes. Should those services be compulsory? Well, maybe. If someone has gone through multiple rounds of treatments, received a designation of within normal limits for their mental functions, and then makes the conscious decision that living with the side effects or pain of their medication, treatment, etc., isn't worth it, when should the state intervene? Personally, I feel they should intervene when they become a danger to others. That might mean removing them from public spaces if they pose a threat to others. That means if they live in the woods, they aren't committing crimes, and are not creating hazards, we shouldn't compel them to inpatient services. I'm reminded of an article about "palliative therapy" for people struggling with terminal eating disorders, who basically decide while of sound mind that the risk of dying is better than living how they feel when they eat healthy. Once normal treatments have been tried, even compulsory interventions, and they still make that decision, why should we continue to intervene if they aren't posing a hazard to others?
There are, of course, folks who are homeless, who aren't a danger to others, and who aren't seeking out housing. I've known some of these folks. They are usually quiet and keep to themselves, but more or less keep up on their self-care, don't make others uncomfortable, or pose a danger. Personally, I don't think we should compel these folks to services.
And there are many other reasons for homelessness, and often a combination of factors. However, what we are lacking is a multi-faceted approach that tackles each of these distinct cases. Many homeless people are not simply people who could be given housing and seamlessly slip into modern society. Many need intensive counseling services to process trauma, harm, drug use, etc. This requires both incentives and disincentives, services, and interventions.
But to get to the premise of the article:
If he continues to be a danger to others, then no. If not, then yes. And I don't know of a different answer that doesn't become an overreach or a failure to balance personal rights. People should be safe in public, but should also be able to exercise their agency, up to the point of becoming a hazard to others.
I visited Portland, OR, in June of 2022 and stayed at a hotel downtown. It was horrible. Needles and fecal matter in the streets, sidewalks full to the curb with tents. I watched, with my boys, as a homeless man threw themselves on the tracks of the trolley, which fortunately stopped before running him over. Decriminalization is simply not enough. Services, incentives, and disincentives, coupled with keeping public spaces safe and sanitary, are needed.
Edit: This ended up longer than I intended, but it needs to be said.
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Homelessness is often talked about as a choice. A choice to do drugs. A choice not to work. A choice not to medicate.
If we're going to have this discussion, especially with regards to mental health, then it's important to put that choice in context vis-a-vis what it means to be on antipsychotics.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9453914/
...
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6127750/
A lot of us have seen the effects of homelessness on our cities. I've spent a lot of time living around Los Angeles, and now Houston. I've had my car stolen out of my driveway. I've found drugs and drug paraphernalia littered around my home. I've had my child afraid to walk through the park alone in broad daylight. I've lived with shanty towns around the block, prostitutes walking the corners, and drug addicts fighting with schizophrenics in the street.
Unlike most people, I've also lived with serious mental illness. I've watched my loved ones live with it. I've tried to navigate the county mental health services, only to be laughed away because other people have it worse. I've had family members speak word salad and talk to voices only they can hear. I've seen and experienced a myriad of horrible side effects, and learned the medical terms for sensations other people can barely describe. I've been there when social services gets called out for a wellness check, and I've seen the fallout when it turns into a 5150.
You know what's fun? Finally finding a psychiatrist who actually gives enough of a fuck to actually talk to you (like really talk to you), getting on medication that actually works without debilitating side-effects, then getting laid off, losing your insurance, and being unable to afford your medication because it's $4k+ for a month's supply (with a coupon, mind you), then begging your Dr for sample packs that you can cut up to try and titrate off so that you don't literally enter psychosis or die from the withdrawal side effects.
Should people be forced to be medicated? Honestly, I don't know. I look at homeless people with debilitating mental illness and think, "That could be me. Or my wife. Or my son. Or my friend." And I think, maybe it would be a mercy. Maybe it would be an act of love to force someone in that state, in the midst of psychosis, to be medicated and brought back to reality rather than leaving them to suffer on the street where they clearly can't take care of themselves.
The question is profoundly complex and I don't know what the answer is. And frankly, it's a topic that few people, on this site and in the general population, have any business weighing in on. Homelessness is a problem, don't get me wrong, and not every homeless person deserves equal sympathy. But if you haven't seen first-hand the stark realities of treating severe mental illness, if the whole of your worldview is based on theoretical or philosophical and how unpleasant other people's homelessness is to you personally, then maybe you should count your blessings and bite your tongue.
I think in these sorts of situations, it is important to have at least one compulsory intervention with follow on treatment, to give them a chance to make the decision in as capable a state of mind as possible, and documented with medical providers. However, if while of reasonably sound mind, they make the choice that the cost of dealing with the drugs side effects is too great, they should be able to make that choice and exercise their agency, at least until they become a danger to others or public safety.
It gets trickier when you might consider a second intervention with the justification that new medications or treatments are available now that weren't 10-20 years ago when they made their choice. I don't know that there is a perfect answer to that question.
It's hard to look at people in apparent suffering, self medicating on unsafe drugs, with untreated injuries or disease, and conclude we should leave them be because they prefer this to whatever was necessary for them to maintain self-care in society. But people do make that decision, as in the article above.
But I don't think we can ignore public safety needs by letting them camp on sidewalks and create hazards in public spaces. That's balancing their rights against the safety of others. They have the right to not take medication, but not to litter parks with used needles, feces, or to harass others, etc.
It's a hard situation to balance. While they should have the right not to take medications, if they can't keep themselves from presenting a hazard, then they should probably have compulsory inpatient treatment, sans medication, as an alternative to jail or being a public danger.
Unfortunately, there isn't a perfect solution for every person or situation, or a fairytale ending.
I tend to agree that intervention and compulsory treatment are warranted in instances where they are an urgent danger to themselves or others vis-a-vis physical violence. I'm less sure about it when the danger is indirect (eg. public hygiene/nuisance issues) or long term as there are other, less invasive routes that can be pursued first to address those specific issues.
One of the complications with compulsive treatment though is that it's not a simple solution when considering the long term view. I touched on it in my previous comment, but treating severe mental illness is neither straightforward nor inexpensive. Even under ideal circumstances medication can take over a month to begin being effective, (that's over a month before you know if you need to adjust the dose or change to a different medication entirely) and the out-of-pocket cost can be in the thousands just for a month's supply of one pill.
Suppose someone is in the midst of a psychotic episode and living on the street. You take them to a clinic against their will, physically restrain them, inject them with haloperidol, and keep them involuntarily committed until they stabilize. Let's assume for argument's sake that the individual is grateful and earnestly wants to continue treatment. What does that look like?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8101248/
Keep in mind we're discussing a segment of the population without any social safety net, likely no reliable support from friends or family, poor job prospects, and of course lacking basic food and shelter safety. Not only would you have to cover follow up consultations, deal with the trial and error of finding an effective treatment, and cover the cost of medication which would otherwise be prohibitively expensive, but you're doing all of this for someone who's environment couldn't be more stacked against them. Treating them just to the point of cognition and then throwing them back on the street to take care of themselves is a recipe for certain failure, and arguably more cruel than if you hadn't intervened at all.
Okay, so then you're willing to go the extra mile and put in the money and effort to make sure your investment has the best chance of paying off. You put them in a job training/placement program, provide them with stable and secure shelter and source of food, and fully cover the cost of treatment programs. All of this with the hope that they'll reach a critical mass of self sufficiency.
First of all, if all of that is necessary anyway to prevent relapse in even the best case scenario, then why not work harder to provide that before reaching a point where we're discussing compulsive treatment?
Second, what's going to happen when the safety net is pulled out from under them? At some point in their journey of recovery they will reach a point where they no longer qualify for assistance. Depending on the jurisdiction, reaching that point late in the year can mean that you are retroactively disqualified, and you get billed for all of the treatment you received up to that point. I've seen it happen. Multiple times. Downright Kafkaesque, but it's the cold reality of how the system is set up.
Again, even if we're just talking about the ethics of compulsory treatment in a bubble, I'm not sure where I stand. Add in the context of this happening within a system that is woefully unprepared to prevent relapse and it just makes things that much bleaker and less clear.
I don't know that we are really talking about the same thing. I was looking at this from a medical ethics perspective and a public policy perspective. The medical ethics perspective is focused on identifying and preserving agency, while public policy is balancing individual rights against the public interest. In order for a patient to decide that they don't want treatment, they need to be at least somewhat capable of making those decisions. Once they have made that decision, further interventions shouldn't be attempted (generally, and with significant debate in the medical field). So when you first discover someone experiencing acute distress or presenting a public danger/hazard (not nuisance), then I don't know how you make the decision not to intervene from a medical perspective, at least until there has been a documented effort and patient decision to forgo treatment. Once they have made the decision to forgo medication, that should be respected. But it also doesn't mean they should be free to continue presenting a hazard.
I posted a longer comment that looks a little more holistically at the challenges in addressing homelessness. And you are right; to recover from homelessness caused by mental illness requires intensive follow-up care.
Now, specifically looking at people with mental illness as the cause of their homelessness, to your point, certainly managing it to start with is best. A Medicare for All coverage system, improved access to mental health services, and ensuring continuity of care would help tremendously. However, like I said in my other comment, you need a multi-pronged approach.
Going back to the issue of balancing public interest with personal freedoms, I think I disagree with your stance that we shouldn't intervene to keep public spaces safe. Used needles, fecal matter, and other common issues in parks, streets, and downtowns habited by homeless persons aren't a nuisance; they are a public health threat and a breeding ground of misery. They also fundamentally destroy a neighborhood's ability to use and transit their public spaces safely, degrading and destabilizing confidence in governance and public services. Now, you didn't say "not intervene"; you said "compulsory treatment" unless other methods have failed, so maybe we aren't in disagreement.
But to be clear, if someone who has clearly documented their conscious choice to forgo medication continues to become a hazard, trespass, etc., habitually, then they may need involuntary detention. That detention shouldn't, in my opinion, simply force them on a drug regimen that they already decided against. But state-funded facilities that can offer inpatient counseling, monitoring, and care better than simple incarceration, are likely needed to at least some extent, which I mention in a different, brief comment.
Does anyone have a link around the paywall? I have an nyt sub for my wife but can't ever remember the login.>_<
This is an archive link.