Civil Commitment: When and Why? A Pained Response to George Savage
When I read George Savage’s moving column on the Tucson shootings, I did not know whether to cry or to scream. The issue that he talks about is simple to describe but it is impossible to solve, or so it seems at the moment.
As a formal matter, the question George asks is this: how do we respond collectively to uncertainty with respect to the future behavior of ominous individuals who as of yet have committed no harm? We have no crystal ball for the future, and thus do not know when the state acts in advance, whether it puts someone under lock and key who in fact will do no harm, or whether its decisive action has saved the lives of many innocent people.
Reading George's account of the situation with Jared Loughner, it is easy to conclude that all the warning signs were there, so that it was a matter of simple public dereliction that he was allowed to remain free. But the nagging question in the case is whether there are thousands like him, troubled and disturbed, who have remained on the streets without causing any harm. We don’t know what the number is, and we don’t know whether a more aggressive system of incarceration would have tapped the people who should be put into custody. Indeed if Loughner had been incarcerated, it would have been hard to tell whether the decision was correct precisely because no harm could take place. So there is a part of me that says George is embarking on a fool’s errand, and that we just have to accept with gritted teeth that in any society with millions of people and millions of opportunities for destructive behavior, we shall not be lucky all the time. Better it is therefore to think about other solutions, none of which work all that well either. Gun control is far from proven. Great surveillance at political events may just lead attackers to shift their focus. It is hard to say.
And yet...In my heart I don’t believe what I just wrote. I can still recall the first time I encountered the issue of civil commitment, and the nervous pit that it left in my stomach. The issue seemed clear enough in favor of the practice when the party subject to commitment had been lawfully incarcerated for an offense that had been committed, only to have served his appointed time. Civil commitment was then sought, and sometimes granted, because prison authorities thought that he still posed a large danger to society. Within that well-constructed universe, there is good reason to credit those findings, for it is not as though we are looking at a random subset of the population.
Unfortunately, we have to dig deeper and take bets with longer odds when the person to be incarcerated does not have a criminal record. I would be comfortable with the conclusion in an individual case that concluded that incarceration was not appropriate if I thought that it resulted from an even-handed judgment of the odds.
But that is not what happened with Jared Loughner. There were warning signs in abundance. The students who protested did so on a prolonged basis. They had chapter and verse about behavior that was too bizarre to be ignored. His college suspended him and told him that he could not return until he had undergone psychiatric testing. Yet nothing coercive was done, even though Loughner’s was not a random case. It was a case where everyone conceded that something bad, real bad, had happened.
So what should have been done? The first point is never—repeat never—let someone who is perceived to be a threat to others determine whether he undertakes treatment and if so of what sort. The coercive power of the state must be introduced. There is no need to leap from preliminary investigation to civil commitment in one easy step. But there is a need first to retain the person for an in depth psychiatric examination and to keep him in custody until that is completed, preferably at all possible speed. It is then critical to obtain a search warrant to inspect his home, his car and his computer to see if they offer, as they did in this case, evidence of a violent streak, especially one targeted to a particular individual.
If evidence of that sort is found, the case should be taken before a magistrate to see if that person should be kept in custody. That hearing should allow him at state expense to hire his own expert to review the evidence and contest the order for incarceration. If, as seems likely with the Loughner case, incarceration is ordered, medical treatment should be provided, but release should be done only on strong proof of a return to a normal condition. There are too many cases on the books of persons with psychiatric disorders who are released only to promptly kill.
These are not criminal procedures, but they are very serious. The blunt truth is once a college or a firm thinks that it has evidence to require treatment, it should take measured coercive steps for the protection of others. And as a society we must not condemn these officials for callous indifference to individual rights, or expose them to tort suits for incarceration at any time. No one likes to incarcerate the innocent. But no sane person could ever be indifferent to the blood and gore that happened Saturday in Tucson Arizona. George Savage is right after all.
- Comment (27)
- · Quote
- · UnfollowFollow (3)
- Pages:
- 1
- 2
- Pages:
- 1
- 2
Comments :
Re: Civil Commitment: When and Why? A Pained Response to George Savage
I don't have much to add to Richard's wise words on this most difficult of problems. All I can say is that the onus for this must be on state and local government, not the federal government (despite the Supreme Court's recent Comstock decision to the contrary). The governments that are closer to the people are the ones with the best information and can develop policies that take the best account of local conditions. This terrible tragedy occurred with a federal representative and judge as well as everyday citizens, but it could just as easily happen at schools (like Virginia Tech), shopping malls, and sporting events of no special note other than the gathering of people. We can also learn from the diversity of policies, and their results, in the states and cities. Arizona policies in this area may be too lax -- certainly the sheriff's ill-considered reaction to the shootings gives me little confidence in the leadership of local law enforcement -- and we should ask what other states have done to strike the delicate balance between freedom and security for that which Richard strives.
Jun '10
Re: Civil Commitment: When and Why? A Pained Response to George Savage
I think the mentally ill kill a lot more people than we'll ever know. Loughner just happened to do it in the most clear and public way possible. If instead, he took his dad's car out on the state highway, and intentionally crossed the centerline to kill a car full of teenagers, and himself, he would've accomplished his ultimate goal that way too. We'd just all assume that he didn't mean to do it.
Jun '10
Re: Civil Commitment: When and Why? A Pained Response to George Savage
Nothing happens out of the blue. Warning signs are always there. Ask any teacher. We get a feel for kids early on as part of the teacher-student relationship. This one is sneaky, that one is lazy, another is quiet and introspective, the kid over there is all bluster and braggadocio, and the one in the corner is CRAZY. And when I hear from astonished parents that little Brian was arrested, I shrug internally and offer a non-judgemental "no kidding?"
The same is true when it comes to crazy adults. You will notice that women will pull their children close when some character in the vicinity displays behaviour that is odd or just slightly off. It's instinctive. They might not be able to verbalize their concern, but they know. We all have this capacity to a greater or lesser degree.
The harder part is to know when to take action. It's a judgement call. Some people will refuse to admit that action is necessary, as with Loughner, but the signs are there. The results are frequently shocking, but in retrospect people will admit they knew something was wrong. I see no solution. But I'm never surprised.
May '10
Re: Civil Commitment: When and Why? A Pained Response to George Savage
I'm generally in agreement with this. What makes me a little nervous is combining more aggressive commitment procedures with the increasing medicalization of our differences (from personality quirks to political diffferences). We've all seen the left attempt to say conservatives are somehow unbalanced, and the field of psychology is not free of political bias.
Again, I support this effort, but I also applaud Professor Epstein's agonizing. Let's make sure we always agonize about these decisions.
Aug '10
Re: Civil Commitment: When and Why? A Pained Response to George Savage
I'd say that, not only is there no need to leap from preliminary investigation to civil commitment in one step, but there is need not to leap in such a fashion:
I know (partly from nursing a dear friend of mine through a rough patch) how easy it is for a person's bizarre behavior to appear threatening to others simply because it puzzles or offends those whose knowledge of that person is not complete enough for them to see how clearly he threatens nobody but perhaps himself.
People perceive others as threatening when they're not all the time, particularly when intense emotions get involved. (Sometimes the baseless accusation "his bizarre behavior threatens me" is used as subconscious revenge.)
Moreover, the deliberately false accusation "he is disturbed and threatening" is used as a bullying tactic all the time these days. This tactic can be part of crazy-making behavior -- manipulative tactics used to convince the wider world that other people are the crazy ones. While these tactics might seem unlikely to succeed, the sad thing is how often they do.
Sep '10
Re: Civil Commitment: When and Why? A Pained Response to George Savage
You have gangs of thugs roaming the streets of most major cities who have demonstrated they are a threat and only the resources necessary to ensure they remain in the poor neighborhoods which they terrorize can be afforded. This situation is met with virtual silence. But let one nut job kill some upper middle class citizens and the pontificating about how we should protect society from people who are perceived to potentially pose a threat gushes forth. What’s wrong with this picture?
Re: Civil Commitment: When and Why? A Pained Response to George Savage
Thank you, Professor Epstein, for your column. I have earlier emphasized the need to compel a psychiatric evaluation, not commitment. However, I now see that one leads to the other. Once Loughner was evaluated and diagnosed as needing treatment, the inevitable next step would be to compel therapy. And we could hardly count on Loughner, at least initially, voluntarily complying with a treatment prescribed against his will, so outpatient management is a non-starter; leaving us with civil commitment. I admit that an appropriate response requires a careful balancing act, and I agree with Professor Yoo that local government is the best place to work out the details.
Jun '10
Re: Civil Commitment: When and Why? A Pained Response to George Savage
Quick question
In a psychiatric evaluation in which a psychiatrist is trying to determine whether a patient is a danger to self or others, is it possible that he would find that a person is suffering from hallucinations and/or delusions but that he/she is not a danger to self/others.
Edited on Jan 11, 2011 at 9:14amRe: Civil Commitment: When and Why? A Pained Response to George Savage
I think you are conflating the problems of violent crime and untreated mental illness leading to mass murder. Garden variety thugs are dangerous but not necessarily psychotic--even the most violent would not indiscriminately gun down young children and elderly grandmothers.
Jan '11
Re: Civil Commitment: When and Why? A Pained Response to George Savage
Count me among the "hesitantly opposed."
We celebrate individual freedom. The price is risking Jared Loughners. The question is whether there's anything we can do to hedge the bet without losing our freedom in the process?
Crimes are "useful," so to speak, because they offer substantial proof that a person is a threat. In the absence of a crime, what can we offer as proof? I'd insist that we never rely on the decisions of any single "authority," even if it's a judge, to take away someone's freedom in the absence of a crime. I wouldn't be comfortable unless a number of people corroborated that a real threat exists. And, it would have to be sustained behavior over time, and it would have to be after the person was formally warned that his behavior was causing concern to the community.
Aug '10
Re: Civil Commitment: When and Why? A Pained Response to George Savage
Leebo:
In a psychiatric evaluation in which a psychiatrist is trying to determine whether a patient is a danger to self or others, is it possible that he would find that a person is suffering from hallucinations and/or delusions but that he/she is not a danger to self/others.
Yes, I think it is.
Firstly, the occasional hallucination is not so rare, as many ordinary people who have, for instance, been feverish or deprived of sleep, know.
Secondly, the question is not do we have delusions (as Freud pointed out, we all do -- they are the filters that help us cope with reality), but whether those delusions are likely to provoke dangerous or destructive behavior.
My own father lived a very productive life as a talented engineer suffering from a mild delusion that people are out to get him. In my father's case, the delusion made him more obnoxious than he would be otherwise, and harmed his personal relationships, but only a really crazy person would have called Dad a threat to society.
Edited on Jan 11, 2011 at 9:33amAug '10
Re: Civil Commitment: When and Why? A Pained Response to George Savage
I would venture a guess that we ,as a society, don't even maintain or update the metrics one would use to get to civil commitment. Therefore, it would be instructive to harken back to what constituted anti-social behaviour to the extent of authorities needing to intervene.
Without going too far back, what does the readership here think would qualify as a "telling act " ? Pulling the wings off a fly ? Killing a dog or cat for no reason ?
Threatening strangers ? Exhibiting weapons to strangers ? Certain words ? Physical traits ? I am reminded of the stories of Loughner's red-faced fist clenching behaviour in class bu his teacher. Unfortunately, the teacher had alot to say about his classroom demeanor, but nothing about any reports to authorities. Once again, the authorities fail. Sheriffs, social workers, people in charge at different stations throughout his life all failed him and thus, society was harmed.
Waiting for the parents story, probably a sad tale of frustrated interaction with the authorities. If there's a file, you can bet that the ACLU is ready to file an injunction to protect it in it's HIPA cocoon.
Jun '10
Re: Civil Commitment: When and Why? A Pained Response to George Savage
Midget Faded Rattlesnake
Yes, I think it is.
Firstly, the occasional hallucination is not so rare, as many ordinary people who have, for instance, been feverish or deprived of sleep, know.
Secondly, the question is not do we have delusions (as Freud pointed out, we all do -- they are the filters that help us cope with reality), but whether those delusions are likely to provoke dangerous or destructive behavior.
My own father has lived a long and productive life as a talented engineer suffering from a mild delusion that people are out to get him. In my father's case, the delusion has made him more obnoxious than he would be otherwise, and has harmed his personal relationships, but only a really crazy person would call Dad a threat to others. · Jan 11 at 9:27am
A person who suffers any kind of recurring hallucinations, should be considered dangerous in my opinion. Just as an epileptic is considered too dangerous to be allowed to drive, a person suffering from hallucinations should not go unmonitored or untreated.
Aug '10
Re: Civil Commitment: When and Why? A Pained Response to George Savage
Leebo: Quick question
In a psychiatric evaluation...
The proximity of quick and psychiatric evaluation in your question prompts me to also mention the dangers of a quick psychiatric evaluation.
It's not uncommon for people seeking urgent treatment for some sort of mental health problem to be initially misdiagnosed, and then have that misdiagnosis dog them like a bad smell, impeding rather than facilitating effective treatment for years. They are lucky if they later find a counselor who, after taking months to get to know them, is able to see past the label and conclude that their initial diagnosis was wrong.
To have a professional who really has gotten to know you tell you that -- after years of chaos, ineffective treatment, and being treated as crazier than you really are -- your problem is not what it was initially diagnosed to be -- that it is often far less bad -- is a relief, but also highlights how much we have to lose by quick diagnoses.
I do not think those who make quick psychiatric diagnoses are falling down on their job. They are doing the best they can. The job's just one where sometimes no one's best is good enough.
Nov '10
Re: Civil Commitment: When and Why? A Pained Response to George Savage
Midget Faded Rattlesnake
Leebo: Quick question
In a psychiatric evaluation...
To have a professional who really has gotten to know you tell you that -- after years of chaos, ineffective treatment, and being treated as crazier than you really are -- your problem is not what it was initially diagnosed to be -- that it is often far less bad -- is a relief, but also highlights how much we have to lose by quick diagnoses.
MFR, in the old days it used to be possible to admit someone for observation and assessment without putting a label on them. I bet you can't any more, given the way the government's medical coding works. In the old days, doctors had the luxury of attempting treatments and continuing to observe a patient for a long time. Most psychiatric diagnoses will not respond to medication for a matter of weeks; these days no one can possibly be hospitalized long enough to determine whether they are responding to treatment.
I am very close to someone who has been hospitalized twice. The first time, a few decades ago, the person was able to recuperate for three weeks before discharge; the second time, only a few days.
Aug '10
Re: Civil Commitment: When and Why? A Pained Response to George Savage
Leebo
A person who suffers any kind of recurring hallucinations, should be considered dangerous in my opinion.
Are you sure?
I will give, as a counterexample, a common, and in my opinion, benign or even useful recurring hallucination: "hearing things" -- specifically, hearing music -- when you're a musician.
Every other musician I've confided in about this says the same thing: they recurringly "hear things", too -- sometimes intensely -- and they can't always distinguish whether the music they're "overhearing" is "really there" or not.
Usually, it's possible, upon reflection, to decide whether the music is real or imaginary, but sometimes the only way to convince yourself that it's not real is to do a little detective work: check your environment for sources of that music, and when you find none, conclude that you must've imagined it.
In my opinion, it is always dangerous to ask a musician whether he hears voices. And if he answers "no", he is likely lying. He hears voices, all right, but they are singing, not telling him that he is being followed, or that he must kill, kill, kill.
The line between imagination and hallucination is sometimes thinner than we think.
Edited on Jan 11, 2011 at 10:54amNov '10
Re: Civil Commitment: When and Why? A Pained Response to George Savage
My one quibble with Professor Epstein's post is the use of the word "incarceration." I have closely observed a total of four inpatient psychiatric facilities, both as a medical student and as a visitor of more than one patient. When I first saw such a facility, decades ago, they were (relatively) prosperous, and the good facilities were well equipped to handle taking care of patients who were dangerous, side by side with those who weren't.
There may be a place for incarceration of the mentally ill--those who have already committed a crime may be judged guilty and insane. But in the old days (and things were in no way perfect, just better than now), those who were clearly insane and might be dangerous, but had not yet committed crimes, could be cared for in very pleasant hospital settings.
For the most part, I favor free-market solutions to all kinds of problems, but psychiatric care is one area where I really believe it is up to society and government to take responsibility. The mentally ill need good, safe, and high-quality care, residential when needed, and we should provide it to them.
Aug '10
Re: Civil Commitment: When and Why? A Pained Response to George Savage
Lucy Pevensie
MFR, in the old days it used to be possible to admit someone for observation and assessment without putting a label on them. I bet you can't any more, given the way the government's medical coding works. In the old days, doctors had the luxury of attempting treatments and continuing to observe a patient for a long time. Most psychiatric diagnoses will not respond to medication for a matter of weeks; these days no one can possibly be hospitalized long enough to determine whether they are responding to treatment.
Dr Pevensie, I sympathize with what you're saying here and suspect that you're right.
Everybody's loss. No wonder some patients are stuck with worse initial labels than they retrospectively deserve -- the worse label may be the only way of justifying holding them for any observation whatsoever.
Dec '10
Re: Civil Commitment: When and Why? A Pained Response to George Savage
George Savage
I think you are conflating the problems of violent crime and untreated mental illness leading to mass murder. Garden variety thugs are dangerous but not necessarily psychotic--even the most violent would not indiscriminately gun down young children and elderly grandmothers. · Jan 11 at 9:15am
I agree that these are two distinct issues.
"Garden-variety" thugs these days aren't garden-variety. The MS-13 member who indiscriminately gunned down a father and his two sons in San Francisco over road rage is a case in point, But these thugs are often protected by so-called community activists who think the police are an even worse enemy.
May '10
Re: Civil Commitment: When and Why? A Pained Response to George Savage
When I was in college, I used to hang out in the halls talking to a guy that lived on my floor. One day I found him sitting on the floor, talking gibberish and swinging a baseball bat. When he finally looked at me it was through me like he didn't know me or that I existed in the same space. He seemed angry and completely removed from reality, but not aggressive. It frightened me, not because I feared him, but because the wrongness of it was so horrific. It turned out that he had developed schizophrenia and I was astounded that it had developed that quickly. One day he was a normal, nice guy, easy to talk to and the next time I saw him he had "snapped". My thought about this is that the healthy minded person I knew him to be would have been horrified to know this would happen to him and I can't believe he wouldn't have wanted his family and a team of professionals to do everything possible to get his mental health back. Even if it meant forcing anti-psychotics down his throat...against his will. I know I would.