Involuntary commitment laws balance the rights of people with mental illness and protection of the public, and the standard for commitment is that the person presents an “immediate danger to self or others.” She didn’t meet the immediacy criteria.
There’s debate over this provision. In New York, we have a law — Kendra’s Law — that allows for broader inclusionary criteria so that, for example, commitment can be based on a person’s history of noncompliance in treatment. A doctor or a family member would have to petition the mental health court in the hospital.
But even if someone had brought her to the right psychiatrist, the question is: What happens after that? In my experience, we would bring people like her to Bellevue, and 30 days later they’d be discharged and back on same heating grate as before.
What if she just did not understand she was mentally disabled?
If you look at her from a “strengths” rather than “deficits” perspective, she was extremely resourceful. She knew exactly where it was safe to stay; she was lucid in interviews; she knew her dilemma regarding shelter — that she felt safer away from people than in a crowded place.
She said no to treatment, no to the shelter, no to a room at the Y, or the Phoenix House. These were reasonable decisions from her point of view, because she saw herself as the star student and not as mentally ill or a substance abuser.
The minute anyone said, “You need treatment,” they got onto the list of people she’d never engage with again. She didn’t want treatment.
What are the options when someone refuses help? What are some common reasons they refuse?
There’s a quote from Marsha Linehan, the famous therapist: to engage with someone like Ms. Williams requires a “radical acceptance of her point of view.”
A program that could offer housing in a dignified way — with no requirement to be in treatment, but a lease, privacy, security — I think might have helped in this case.
I’m not saying that involuntary commitment is off the table. I’m being pragmatic. If commitment is the right thing to do, then let’s do it, take the person to Bellevue, and get meds — that’s fine. But many people in these circumstances need other options.
Why do so many people like this end up homeless or in jail? Is it the lack of beds, or the law?
There is overrepresentation of people with serious mental problems on streets who then end up in jail. If someone has a mental illness and they’re not working, and they lose their housing — then unless they have someone to help, they’re at high risk for homelessness. Once you’re broke and on the street, there’s no way you can come up with the first month’s rent and a security deposit for an apartment. You’re not getting back into housing.
And yet many programs that try to help require treatment first, before anything else. In this case, if you managed to get her to a hospital for treatment, or involuntarily committed — well, as soon as she’s out, that’s the end of that relationship.
Under New York law, what is the procedure by which a person like Ms. Williams, who’s putting herself at risk, could be treated involuntarily?
You would have to make the case by petitioning the mental health court in a hospital. This can be a family member, or a member of a treatment team — one of the mobile teams, who have been trying to get her treatment — would have to make that case that she’d been noncompliant with the treatment and is a danger to herself.
And sometimes that kind of intervention is effective. The order allows you to bring the person back into the hospital if they’re not taking their meds. On the risk side, it creates an adversarial relationship. You’re supposed to be helping this person, and yet you have the authority to yank her back to the hospital when things aren’t going well.
Is there a better way to balance people’s right to make their own choices and their health?
I would ask: Why do we have homelessness to begin with? Why is it that even this woman, a graduate of Williams, ends up on street? How is it that we don’t do something about that first? More mental health treatment is not going to help people find a place to live.
The idea of choice is intimately connected to radical acceptance of another person’s point of view: whose choices matter most, and whose are most effective in solving this problem.
People can’t imagine this woman living in her own apartment. But she stayed with a friend in Brooklyn, on the couch, and did fine. And she navigated her way to California, and to Washington D.C. If she can do that, she can navigate her way around an apartment.
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