God Knows Where I Am

I have been asleep at the switch on the story of Linda Bishop, who was a patient at my hospital in the 2000’s, refusing treatment and eventually being discharged, after which she moved into an abandoned farmhouse and eventually starved to death. It was written up well in the New Yorker in 2011 and I recalled reading that. Since that time it was made into an award-winning documentary in 2016, “God Knows Where I Am,” which I had not known about. I’m not sure how I missed that. Asleep at the switch, apparently. I knew nothing about the case at the time, but her entire treatment team were all people known to me. I worked that unit at other times. I think they are all gone from the hospital by now. The discussions they had are ones I have had repeatedly through the years as well. A person is psychotic, but displays no measurable dangerousness. In the protected environment of the hospital they are able to eat, stay clean, and clothe themselves. They go to a cooking group, make food, and answer a nutritionist’s questions intelligently. Whatever we suspect, we are hard pressed to offer much evidence they won’t be able to care for themselves. We might apply for a guardianship, but the standard for proving that a person is unable to make decisions on their own behalf is high. It is not enough to demonstrate they make bad decisions. Half the state of NH makes bad decisions but we don’t lock them up and get them a guardian. The bar is high because we want it to be high.

Her story is poignant, and provoking, but all the commentary in all such stories seems to say the same ridiculous things over and over. She fell through the cracks of the mental health system. No she didn’t. The story/film calls into question a system where a person who doesn’t believe they are sick can make decisions for themselves. No it doesn’t, not really, neither the legal nor the mental health system. The hospital refused to notify the family because of HIPAA laws. What’s this word “refused” in there? Do we say that the sheriff “refused” to tear down a building because of zoning laws? As in my post three years ago about the word “systemic,” we use that word system as an evasion. Systemic racism means we can’t actually define what we’re talking about, but we want bad things to stop happening so we start kicking the machine in random places. Someone will pay, dammit!

Tangent: When it’s New Hampshire, people from other places always have to work in the “Live Free Or Die” angle too. NH actually has more protective (and intrusive) mental health laws than nearly all other states. Try to get someone committed to a hospital in Vermont or Massachusetts sometime. The magazine writer and the filmmaker are from New York City, where you actually can die on the street without many people noticing. But it’s fun to pretend it’s one of those backward other states instead.

So…You are fifty years old. If you get admitted to a hospital do you want your mother notified without your permission? Your sister? We have privacy laws for a reason, and when we pass them we generally intuit the plusses and minuses pretty clearly. This is also true of laws committing someone to a hospital against their will, or appointing a guardian over their decisions. We set a bar that must be reached before we take rights away from people. These are not made in ignorance of what will result. Changing mental health law even a little bit is very difficult, I can assure you. The idea that all these problems are new, and no one really ever thought about them before, but now this new story comes up to awaken us to the idea that OMG, something might go wrong here, and maybe this will inspire people to action so that she didn’t have to die in vain…it’s all hogwash. This story came to the fore because she was white, well-educated, a mother, gentle, had an artistic streak, chose an environment that had some elements of beauty (Farmhouse! Orchard! Brook!) and wrote things in a diary expecting a lover to rescue her, a very old-fashioned attitude like women in books. People who are less white and educated, with less romanticism or in uglier places have this happen all the time. It’s not some failure of any system. It’s exactly what we thought it was when we passed those laws. We just want to have things both ways, that’s all.

I rail against arguing from anecdote. That’s all this is. It just happens to be an anecdote that hits closer to home, and told particularly well. Sad for the family. Sad for lots of families. If you want to change commitment or guardianship laws, go for it.

30 thoughts on “God Knows Where I Am”

  1. Sad, poignant story. Can’t argue its tragic nature, either.

    However, it has to be pointed out that it exists at the collision point of contradictory interests, goals, and desires. You want people to be free, possess agency, and to make their own decisions? Well, things like this are going to happen. It really isn’t all that much different than watching a beloved relative drink themselves to death, and there’s really about f**k-all you can do about that, either.

    I don’t like the fact that the drive to de-institutionalize the mentally incompetent has led to this, but at the same time… Who the hell are we to force someone into “treatment”, and how do you justify that in terms of restricting their freedoms? I’ve known a couple of functional loons in my time, and I’d really rather not be the party that tried to confine them to some drab existence in a psych ward. The less functional ones, sure… They’d be better off there than freezing in the dark somewhere. But, where do you draw the line? Who draws it? How do you prevent abuses?

    In the end, we have to acknowledge that consciousness and agency are poisoned chalices for a lot of people who can’t keep it together to function, and that there are a lot of folks out there who barely manage to keep on this side of the line. The marginal cases are disturbing, but their fates are unfortunately out of our hands. When you consign your friends and family to the mercies of the state, the results are very often not pretty, at all.

    I’m still not convinced that we’ve managed to arrange things in a superior manner to the “old days” when ones family was responsible for you and did what it could to care for you. In colonial times, this poor woman might have done better, or she might have wound up chained up in an outbuilding somewhere. A more compassionate and personal system might have allowed her to eke out an existence free of starvation and suffering, but I suspect that there were still cracks someone like her could fall through.

  2. Who the hell are we to force someone into “treatment”, and how do you justify that in terms of restricting their freedoms?

    Hence the explosion in the “homeless” (i.e., vagrant) problem, especially here in California, where we encounter raving psychotics on a daily basis. They’re just listening to a different drummer, right?

    In our sleepy burg we recently had two murders by vagrants, in one of which two such vagrants broke into a tony condo and stabbed a woman 147 times. THAT’S how I justify restricting their freedoms. Specifically, their freedom to be antisocial – and all too often murderous – parasites.

    My wife is terrified to walk in some parks and through some pedestrian overpasses to the beach where our “free spirits” have set up housekeeping, and periodically knife passersby.

    So bugger their “freedoms.” Normal, productive, law-abiding, taxpaying people have some rights here too, a fact that apparently has escaped attention.

  3. I’ll take your word that it’s a good write up. After you gave up the twist ending, the interminable “New Yorker” style made my eyes glaze over if I tried to skim more than every fifth paragraph.

    The only thing I could see that made Linda, beyond the unusual way she died, stand out was that she actually had extended treatment rather than a random scatter of 72 hour holds. I doubt you’d have much trouble finding several equally disturbed in any collection of homeless.

    I wonder if the author’s next article wasn’t about some misunderstood person she found unjustly institutionalized in New Hampshire.

    The simple truth is that anyone in that condition is completely vulnerable to their own disordered decision making as well as anyone that cares to exploit them. A few can keep some sort of family support or will maintain their medication on their own. The rest are far more likely to get long term treatment in prison than in any sort of hospital.

    Outside the rather bizarre circumstances of her death, it’s hard to see why this is even newsworthy. This isn’t even a good example of the failure of the system. The system worked, the patient failed.

  4. The kid in Krakauer’s book “Into the Wild” is another such. the kid was not overtly psychotic but he had plenty of weird behavior.

    The summer of 1962 I worked in a VA psych hospital in Los Angeles doing annual physicals on psychotic men who had not had an exam like that in years. Deinstitutionalizing has been a tragedy.In 1962, Thorazine and Stelazine had made their care far easier but they were still crazy, in their favorite term. I actually gave some serious thought to Psychiatry until I met more psychiatrists.

  5. Jay,
    That’s part mental health, part criminal justice ‘reforms’. If we were locking up people for vagrancy, drug use, and petty theft, it wouldn’t matter so much that we are also not locking them up for not taking care of themselves.

    And what constitutes lack of self care? It can be observed that much of what psychiatric and psychological organizations find politically convenient to endorse are in fact things that could reasonably be considered harmful. If we had many asylums, the lunatics might well be running them.

    Caring for someone who is mentally ill is expensive. They have a tendency to make a certain sort of bad decision. So you can stop them from making that decision, or you can stop that decision from mattering. Which is one order of difficult if you can get cooperation, and another if you are using only force. Confining people and coercing them takes force, and gets very costly if you don’t want to hurt them badly in the process. For a given level of productivity by a population’s well people, confined care can only be funded for a small fraction of a population. Which is potentially doable if mental health issues are a constant, and only make up a sufficiently small fraction of the population. We can also work out that mental health issues are not constant, and can perhaps be significantly increased even beyond the current level.

    My firm belief that part of the answer lies in capital punishment for substance abusers means I fit two criteria. a) “He is crazy” b) “He has a desire to harm others”. Objectively, everyone has policy preferences that could be understood as harmful, and resulting from factors that are not rational. What threshold to confine to prevent harm to others? We obviously cannot confine everyone, and political minorities have incentive not to make the threshold too easily met.

  6. Bob: “My firm belief that part of the answer lies in capital punishment for substance abusers …”

    That is what happens in a poor society. The substance abuser, mentally ill, criminal, etc in days gone by were either left to die, executed, or transported to Australia (where many of them died).

    In today’s rich society, we look after people like that. Commit a murder, and you get an approximate $2 Million gift from the long-suffering taxpayer for lifetime accommodation, health care, legal representation. We treat certain disabled people equally generously; once case I am aware of involving a mid-30s woman with the mental age of about 4 — the taxpayers provide her a house, a car (driven by her support team of trained care-ers), full domestic & medical support; it may take the contributions from about 20-40 taxpayers to support this one woman.

    When the Usual Suspects try to make our societies poorer through excessive regulation, excessive litigation, Global Warming Scam, Covid-19 Panic, etc, they are hastening the day when we will no longer be productive enough to treat such people so generously and so kindly.

  7. They have a tendency to make a certain sort of bad decision. So you can stop them from making that decision, or you can stop that decision from mattering.

    Back when I worked in that VA psych hospital, I worked for a guy named George Harrington, probably the most impressive man I ever met in Medicine.

    Born in Independence, Missouri, Dr. Harrington attended the University of Kansas, where he received his medical degree in 1941. He also played football for the university. He then interned in Chicago, and during World War II served in the Pacific theater as a Navy flight surgeon. He was the recipient of a Personal Citation, Distinguished Flying Cross, and four Air Medals as a result of his service. In 1946, Dr. Harrington began his residency training in psychiatry at the Menninger Foundation of Psychiatry, and became a faculty member at the Menninger School of Psychiatry. He also served as chief of professional services at the Winter VA Hospital in Topeka, Kansas and was a member of the American Psychiatric Association. In 1955, he moved with his family to Pacific Palisades, where he began private practice. He was also a clinical professor of psychiatry at UCLA and head of psychiatric services at Brentwood VA Hospital until 1965.

    That’s from his obit. The only source for his methods in dealing with psychosis (He did not consider neurosis abnormal) was a book written by one of his UCLA residents called “Reality Therapy by William Glasser. In the 60s, when LAUSD cared about children, that book was required reading for teachers.

    Harrington was a great big guy who walked with a pronounced limp from a femur fracture he suffered in an auto accident. He had just finished his residency and now he was in bed in traction for weeks. Then he saw a report on Thorazine and he told me “I was lying in bed before I ever got to start practice and somebody invents a pill that cures psychosis.” Of course the extrapyramidal side effects appeared and reassured him that psychiatry was not over.

    His size and the limp had interesting effects on his patients. He was a terrific guy.

  8. Bob,

    Thanks for your reply. The problem does indeed result from the confluence of mental health and criminal justice policies, both of which are badly flawed.

    It is difficult to convey in words the acute problem from vagrants currently faced in coastal California. The climate – both meteorological and political – combine to exert a siren call to every layabout, druggie, and lunatic in the country. This will provide the flavor:


    (The “A” sign at the 2:00 minute mark is Angel Stadium.)

    The train between SD and LA passes right next to the route shown above, and from the train you can see chain link fences separating the backyards of houses from vagrant encampments. Those poor homeowners are trying to raise families literally feet away from the vagrants. They cannot, of course, move away, for who would be crazy enough to buy their houses?

    I’d say that deinstitutionalization (aka “care in the community”) has now been given a fair trial. The jury is filing back, and they’re grim-faced.

    The same goes for liberal policies, which not only tolerate such behavior, but actively encourage it.

    Many, if not most, of the vagrants are drug abusers as well as many cases being mentally ill. I understand that institutionalization of the mentally ill, and incarceration of the criminal element, are expensive, but so is tolerating parasitism on this scale. Consider how these people live: either on the public teat, and/or through crime, since they’re obviously not productively employed.

    But as you say, simply enforcing laws against petty theft, vagrancy, and drug use would go a long way to addressing the problem.

  9. Thanks for your reply. The problem does indeed result from the confluence of mental health and criminal justice policies, both of which are badly flawed.

    The mental health thing is subjected to all sorts of crazy (pardon me) theories about personal freedom and libertarianism.

    The best source on this is “My Brother Ron, “ by Clayton Cramer.

    He has the best description of the problem I’ve seen.

    As for crazies, This guy is a major barrier to any sensible solution.,

  10. My Brother Ron, should be required reading for every person in this country of voting age. I’ve bought and given away at least 20 copies of that book. Clarity on a very difficult societal problem. Here in Los Angeles we have added the drug-induced mentally ill (in many cases the tax-payer providing the money to procure drugs) to the already deinstitutionalized mentally ill and it is destroying our city and society.

  11. I think it’s fair to say that deinstitutionalization has been an unmitigated disaster. I was in Berkeley when it went into full swing after O’Connor v. Donaldson, and the city was overrun with recently released lunatics, a category in which Berkeley hardly needed any top-up.

    The campus and Telegraph Avenue were well-stocked with people having heated arguments with invisible interlocutors. One favorite: a guy standing at the corner of Bancroft and Telegraph (i.e., at the south entrance to the campus) wearing an obvious Salvation Army tweed jacket several sizes too large for him, holding an unstrung tennis racket that bore a sign reading, “The DA’s office is controlled by crooked psychiatrists.”

    Another was a Carrot Top look-alike who always had a bag of oranges over his shoulder, and who spent his day walking straight across Sproul Plaza until he encountered an obstacle, when he would turn at right angles and resume walking. We called him the Random Walk Guy, a sort of human version of a Pong game.

  12. It’s not like institutionalization was a lot better. The institutions that you heard and still hear about are invariably because of abuse, neglect, incompetence or corruption, usually more than one.

    One of the things I found unusual about Linda’s story was that she was allowed to opt out of the drugs. From what I’ve read, even when drugs are effective, the side effects make getting the patient to take them consistently a never ending struggle. A lot of the people on the street were in either some sort of community based treatment or had family to motivate them to stay on their regimen at one time. Most simply walked away.

  13. The crazy and the evil are why God gave the Inuit ice floes.

    A lot of my ‘taking care of the mentally ill can be done for love, or money, and there ain’t enough money in the world to be spending it on everyone’ is partly inspired by an actual possible success for deinstitutionalization. As an aside, one of those lunatics who was drawn to California, which is a major reason why I am aware of California’s recent permissive policies on mental health. A lot of bad decisions along the way, unnecessary costs, but probably on net a did more good outside of the hospital than would have resulted if they had stayed in forever. But they stayed away from recreational substance abuse, and generally heeded medical instructions. So my personal opinion is that there are people I’m unwilling to simply forcibly confine. People I’m willing to try to care for outside of psychiatric institutions. Possibly I’m excessively generous, and I’m contributing to family error in continuing forward with those decisions.

    I think we definitely probably should adjust the process of confining people for mental issues a bit more in the confinement direction, but I don’t have specific suggestions.

    That is part of the reason I am so insistent on prioritizing the changes with how the recreational drug users are handled. (And I don’t buy ‘self-medication’ as an excuse with most of these substances. If you are crazy, and a chemical adjusts your thinking to normal, you need an outside perspective on your thinking to make sure the dosage is right.)

    Recreational use hurts the ill, and is bad for some of the people who are otherwise healthy enough that they could function in society.

    We have a bunch of people in prison for drug offenses. If we killed them all, we would have more space and funding for petty criminals that haven’t been caught using drugs. As well as resources for the naturally ill.

    Issue is, my belief that the choice to start drug abuse is the one that puts a person beyond the bounds of society is specific to me. It isn’t shared by society, and definitely wasn’t shared by society at the time some of these people were arrested and convicted.

    The theory of not executing criminals is partly dependent on prisons being able to hold people, to prevent them from hurting others, and preventing others from fearing being hurt by the ones who are family or physically close. The excuse of Covid-19 for releasing prisoners is bullshit, and fundamentally undermines the part of the consensus opposed to capital punishment.

    It is not clear that the Georgia vigilante killing is the start of a wider trend resulting from how badly the legal system has discredited itself. It is not clear to me that we have a path out that does not include vigilante killings of junkie vagrants, etc.

    We certainly don’t have enough social condemnation of drug abuse to use that instead of heavy handed punishments.

  14. Mike K, thanks for the recommendation of “My Brother Ron.” I just picked up a copy from Amazon.

    The lunatics in Berkeley were amusing (generally), but those nowadays not so much.

    Two years ago a guy tried to shoot up a nearby elementary school, and brought along a propane cylinder with a view to blowing it up as well. Fortunately, he was tackled by a gardener before could carry out his plan.

    Turns out he was frequent flyer with the local gendarmes, who were called to his house by neighbors literally on a monthly basis for bizarre behavior. But he did not pose an obvious imminent threat, so the cops had no basis on which to hold him.

    Last summer one vagrant stabbed another, who staggered across the street and died in the doorway of a shop adjacent to the one where our younger son was working.

    This was not in a battle zone, but rather in one of the toniest communities in coastal California.

    The situation is getting intolerable.

  15. The situation is getting intolerable.

    Theodore Dalrymple, in Fool or Physician: The Memoirs of a Sceptical Doctor recounts an incident in which the wisdom of the uneducated villagers is far superior to that of the ruling Bien Pensant ruling elites:

    “About a week later I was again on duty when a man was brought to hospital with a gash across his neck. Had it been a fraction deeper he would undoubtedly have been killed. I was surprised to learn that it was the same man who had attacked him as had attacked his wife the week before. He had been released on bail and that night had gone to a bar where he had become drunk. He took out his knife, went up to the man who was a stranger to him, said ‘I’m going to kill you,’ and cut his throat.

    The next morning the police asked me to talk to the man, who was in their lockup, to determine whether he was sane. He had sobered up by then, but showed no remorse; he was not concerned with the fate of his victim, and took the attitude that these things happen. I reported that the man was not insane but – surely a conclusion it required no training to reach – was very dangerous, especially when drunk, having attempted to murder two people in the space of a week, and having also a conviction for murder. In that case, said the police, they would have to release him again on bail; for if he were not detainable in the Mental Wing, they could charge him only with wounding, a charge for which the granting of bail was mandatory. I protested. Surely, I said, the charge should be attempted murder; but the police, whose understanding of the law was fragile, insisted on releasing him.

    That night, while the released man was sleeping in his hut, a group of ten villagers entered and stabbed him to death. His ragged corpse was brought next morning to our mortuary, where it attracted a festive crowd (as did any corpse). But the whole episode must further have lessened respect for the European’s alien system of law, which had so signally failed to protect the community.”

  16. I’m getting a sense that many here believe the mental institutions were just warehousing people. That was true until the first drugs came along that worked. They were Phenothiazines, another product of the German organic chemistry industry of the 19th century

    The effect on psychosis was first noted in 1952 by a young woman psychiatry resident in Canada. It soon became the first effective drug for schizophrenia. By 1962, when I encountered it, the side effects were well known but mostly controllable. They did, however, add to resistance to long term use. Other drugs followed with less reactions. Haloperidol appeared in 1958. The “atypical” drugs in the 1970s.

    What Harrington was doing was using the drugs to allow patients to transition to a more normal state. Few were able to resume normal lives but many of his patients were able to transition to sheltered half way homes run by adults trained to recognize backsliding behavior, signs of psychotic thinking and behavior. The hospital was always there to support the outpatient status. If the patient began behaving in a more psychotic manner, he could be returned to the ward. This, rather than punishment , was reassuring to the patients. It meant that the doctors knew they were still crazy and refuge was available if it got too frightening outside.

    He told me a story of a commercial fisherman who was schizophrenic but was able to work offshore for months at a time. Every six months or so, he would show up at the therapist’s office and spew a bunch of crazy talk. Thus, having re-established his status, he could go off and live his life. Not a normal life, no wife and children, but one that was productive and supported him.

    After 1965, this was all destroyed,.

  17. “After 1965, this was all destroyed”

    “This” sounds a lot like the community care that was supposed to allow these patients to be de-institutionalized that never actually materialized after the hospitals were closed.

    “This” would have been far cheaper than maintaining the hospitals also. Unfortunately, what was cheapest of all was to simply close the hospitals.

  18. I was under the impression that deinstitutionalization was driven not by financial considerations but by judicial decisions, particularly the Supreme Court’s 1975 decision in O’Connor v. Donaldson.

    Since we have people here who are knowledgeable in this area, can anyone confirm or correct that impression?

  19. The book, “My Brother Ron” has a better history of the legal story than my medical history book. If you are going to read it, that is the best source. What happened was the lawsuits by “dogooders” and crazies let the Governors take advantage with the libertarians, etc as cover.

    This history is not bad although it glosses over the bad effects a bit.

    1962 – Ken Kesey published “One Flew Over the Cuckoo’s Nest.”13 It was a fictional story about abuses in a mental hospital. The author dramatized his experiences as a nurse’s aide in the psychiatric wing of a California veteran’s hospital. The book helped turn public opinion against electroshock therapy and lobotomies.

    1963 – President John F. Kennedy signed the Community Mental Health Centers Construction Act.10 It provided federal funding to create community-based mental health facilities. They would provide prevention, early treatment, and ongoing care. The goal was to build between 1,500 and 2,5000 centers.14 That would allow patients to remain close to their families and be integrated into society. Many of those in hospitals had no families.

    1965 – President Lyndon B. Johnson signed the Social Security Amendments of 1965. It created Medicaid to fund health care for low-income families. It did not pay for care in mental hospitals. As a result, states transferred those patients into nursing homes and hospitals to receive federal funding.

    The Kesey movie had a huge effect. Psychotics were “just different.” It was devastating, sort of like the “JFK” movie for history.

    Something like a third of prisoners in prisons are psychotic.

  20. @ MCS – patients say the side effects are intolerable, and sometimes they are quite hard to live with. More commonly, they are minor or nonexistent but the person simply does not believe they have an illness and does not want the insult/inconvenience/expense of taking them. As I have dealt with the acute emergency group my entire career, my impression may be skewed in the direction of overestimating the percentage of those who simply have no insight and don’t want treatment. Basically, if the state cannot convince a judge of serious dangerousness, you can go off the meds. Your family may abandon you and your life may suck, but you can’t be made to take the meds. A recent NH Supreme Court case may be of interest. A 94 y/o woman was convinced that the town officials of her little burg were all against her and wanted to poison the air in her little shack to force her out so that they could sell it for lots of money. (As is natural in the course of such illness, she developed an explanation to go with it why her house was suddenly so valuable.) She refused to move, and left her windows open all winter, wrapping up in more and more blankets to ward off freezing. When she was brought to our hospital we thought that would be enough to prove she was dangerous to herself. She was originally given an involuntary commitment, but it was overturned on appeal. Her attorney pointed out that she had kept enough heat on at a low level to stay alive with the blankets, even though the pipes had frozen, and was able to make food and stay alive. (She went home. I don’t know what happened after.)

    @ Jay Guevara – it is legality more than cost, yes, and has been since the 60’s. The requirement that we find the “least restrictive alternative” is supposed to guide our decisions. We end up playing hard against the edges of that often, bending the law because we perceive dangerousness. However, the cost aspect is never far out of the picture either. The state hospital is a large chunk of state budgets, and the taxpayers don’t want the bill to do this right. Your best guarantee of your civil liberties is that we just haven’t got room to keep you if you aren’t dangerous, because there are so many out there waiting for the bed.

    BTW, that does come into news stories that circulate at times, especially on conservative sites, of someone who got locked up “for nothing” because of some argument with his wife or because the local PD doesn’t like him, all of which, he thinks, should somehow make us afraid of the incipient police state or whatever. I default to disbelieving those stories at this point, having seen the other side of them so often over the last four decades. It’s not that they never occur. I have seen a few where someone was railroaded a bit to come to our facility on the basis of very little. But it’s rare, and we don’t keep them long. We do our research very quickly in those cases to move things along. Maybe it’s different in other states.

  21. AVI,
    Am I correct in thinking that the reason Linda was ultimately released was that the charges that instigated the original finding of incompetence were dropped and she became less obviously ill?

    I’ll gladly take your word about the side effects while observing that it doesn’t really matter why they stop. My point was mostly that it seems to take some sort of outside agency to keep them on the drugs. Most won’t do it for long on their own.

    When they are being treated successfully, it’s hard for a lot of people to believe that there is any reason that they should be deprived of their freedom.

  22. With my short stay in the VA system, I did see a few abuses. For example, with service connected cases, the family got the vet’s family allotment They were often reluctant to accept them home.

  23. @MCS – great question. I was not in the room, but having been in the discussions before, I think they would have revolved around “Is she actually dangerous?” Homicidality and suicidality are clear dangerousness, but the third category “inability to care for self” is much tougher to nail down. One can imagine – in fact I have sometimes seen – unusual survival situations that would have worked. A family who took pity on her and let her stay, craziness and all, or even some guy who kept thinking maybe she would fall in love with him and he’d finally have a girlfriend. She went and got apples from the orchard under cover of darkness, so she wasn’t stupid or entirely helpless. This same sort of ability to reason somewhat would have been apparent at the hospital. Our usual approach is to go for guardianship. That failed, likely because she could give some sort of answer. The tests given include things like “What would you do if you fell and broke your leg?” She may have answered Call 911 or Go To An Emergency Room, even if she wouldn’t actually do those things. She might not even be conscious of being deceptive about it. Those are correct answers to the question and she might say them. Psychosis can have strange gaps. People might click on five cylinders out of six better than half the staff.

  24. Sorry to miss the other part. There would also be the questions “Is there anything further we can do?” “Is there any chance that keeping her for her whole commitment would result in a different prognosis?” “Well, then, aren’t we simply depriving her of her freedom for nothing?” “Don’t we have much more dangerous people waiting for her bed?”

    We discharge people way more dangerous than her all the time. We live in a world of dangerous people. (Even in NH, with its ultra-low violent crime rate.)

  25. BobtheRegisterredFool
    We have a bunch of people in prison for drug offenses. If we killed them all, we would have more space and funding for petty criminals that haven’t been caught using drugs. As well as resources for the naturally ill.
    Actually, not as many as a lot of people believe. Fifty years ago in TX, possession of a joint could, I believe, get you 8 years in prison. Not so today.

    TABLE 13
    Number of sentenced prisoners under jurisdiction of state correctional authorities, by most serious offense, sex, race,and Hispanic origin, December 31, 2016

    All prisoners: 1,288,466
    Most serious offense:
    Drug possession 45,300
    Other (trafficing etc.) 144,800

    Table 15: 47.3% of prisoners in federal facilities are there for Drugs. More than 99% there for trafficing in Drugs. (79k of 167k)

    USDOJ: Prisoners in 2017

  26. AVI,
    My thought was along the line that here was an intelligent, somewhat self aware and deeply disturbed person with a trial and probable jail sentence as soon as she was found to be competent. It probably wasn’t very hard for her to stay incompetent. Once charges are dropped, she has every motivation to get out. The system, as you say, is predisposed to let her out. She was apparently able to dissemble well enough to get out.

    You and your colleges are probably a lot harder to fool than I am, but, as you say, fall short of omniscience. If she had been less capable of functioning, she would probably be alive.

  27. @ MCS – We have many times noted that some very smart people might have had better lives if they weren’t so able to keep everyone away from intervening in their illness. Speculation. We do that when we are frustrated. But as as for prediction in general, the field as a whole is not much better than an average thoughtful person who knows a few statistics. For example, in predicting whether a sex offender will reoffend, two things dwarf everything else: if they are head-injured and if they are abusing substances. Now that you know that you are moderately skilled in evaluation, especially if you don’t try and get tricky by learning more.

  28. Psychosis can have strange gaps. People might click on five cylinders out of six better than half the staff.

    One of the craziest patients in the VA that summer had been psychotic since Anzio in 1943. Shell shock to psychosis for 19 years. He talked in word salad most of the time. He was also the one who told me that talking to me, where I would talk only to the rational part of his thinking, was allowing more of his mind to “come out” of the craziness.

    While this was most of his life, he had a pass to take a bus to UCLA where he was getting a degree in Mathematics.

    One of the most dangerous patients on the locked ward, with a history of “elopements,” was a big black guy who had received the “Order of the Palm” from USC, meaning top GPA, then had married the daughter of a famous public figure (rumor had it it was Dean Acheson) before his psychotic break.

    Psychological testing, I was told, suggested he was not psychotic at all.

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