Throwaway05
16d ago
They get diagnosed with fibromyalgia, CPTSD, hypermobility/EDS, or early onset arthritis. You give up hope they’ll ever be normal.
One of these is (superficially at least) not like the others and that also reveals the likely cause.
I think it is important to emphasize that to some extent we (western medicine) know what this kinda of life experience is about and how to treat it for quite a few people, and at the same time people are not excited about what needs to happen.
This is tough.
I imagine you've had this conversation before and likely are not excited about it, but it must be said both for you and anyone who happens to reading.
Chronic pain comes from a variety of places yes, but absent a physically traumatic event it is often psychiatrically mediated (and things like TMJ point to that). If it is not psychiatrically mediated, then psychiatric care is often important because chronic pain can cause psychiatric dysfunction (ex: depression from being in pain all the time). Either way - part of your care should involve sustained psychiatric follow-up and that would likely improve quality of life.
It is not uncommon for patients with stories like yours to not be down with this.
Often it's because the experience of pain is labeled in some way as "all in your head" and that gets mentally converted to "not real." Well it is real, it is pain those kind of patients are feeling that can respond to treatment but that treatment is generally things like lifestyle modification and psychiatric care and people want a procedure to be done or a "real diagnosis" to be dropped instead often because its simpler or more ego-syntonic.
Some doctors will take advantages of this because they have a research base stating that certain stuff they can bill for will work (and it can) but it also provides risks and has tangible financial costs. That doesn't mean it is the best thing for people (or the best use of resources).
I hope you are better and continue to get better than that but if you are unsatisfied with where you are the best thing you can do for yourself is seek psychiatric help, cases like your own almost always benefit from psychiatric assistance.
Throwaway05
1mo ago
In ye old days we gave you a physical prescription that you could take with you, show up the pharmacy and shout "gib dis" and if they said "no have" you could take the same piece of paper to another place.
Now we mostly use electronic medical records and we ask you what your pharmacy is and send the information directly to that pharmacy.
Why do we do it that way? Likely things like "regulatory burden" and "let's not accidentally D-DOS the pharmacies with all of these requests."
Now I personally prefer paper script pads for some types of things and ask for them myself, but if your doctor does not allow that it likely it is because whoever owns them (large hospital system or PE firm) does not permit them. We don't complain too much because handwriting a prescription is a pain the ass and our handwriting is more ass.
Throwaway05
3mo ago
Your story about "Daily Kos grandmas" who literally don't remember what they used to believe in is of course nonsense (just like all those Never Trumpers who are now MAGAs do, in fact, remember what they used to believe in). People remember, they just rationalize it or else they develop coping mechanisms for the cognitive dissonance.
I'm not sure this is the case. The one that sticks out to me the most is the initial response to COVID. So many people don't remember the early days where believing in COVID was racist and bad. They just swapped back and if you try and remind them now you'll get a lot of "holy shit I forgot about that" or "no way!!!!!!"
Throwaway05
14d ago
Absolutely, and while overt delusional beliefs are what pop to non-medical people seeing or hearing about these patients, the real problem is the negative symptoms of schizophrenia (often manifesting as a total inability to care for oneself in a functional way). That is much less exciting but more important for commitment purposes a good chunk of the time.
I think a lot of the doubters here would be way more comfortable if they had a chance to stay in a city crisis center for five minutes.
Throwaway05
3mo ago
The Great Books program is specifically supposed to be a replacement for a traditional college curriculum in which you learn things from primary sources in and see Western Civilization being shown off.
Much of what you ask for is contra to the mission - if you made the changes you are suggesting it would be something else.
It's like getting annoyed at Western Canon lists for not having Eastern material.
Throwaway05
14d ago
To be clear: you want the state to summarily execute between 5-10 percent of the population because of the presence of severe mental illness?
Throwaway05
14d ago
The legal system in many places in the U.S. has abandoned intervention when a problem is a psychiatric matter and not a criminal one. Some of this is clearly inappropriate such as situations where the police are exhausted or the DA refuses to get involved. Sometimes it is appropriate, if someone is a chronic schizophrenic who has lost touch with reality and is violent then it's not a criminal problem, the guy is obviously not guilty by reason of insanity.
The person does not belong in jail they belong in a state hospital, this issue in part being that the funding for those beds has been taken away so traditionally these days they go to jail instead (it's just not the correct disposition).
Throwaway05
14d ago
I frankly have no idea how the judge in question here can honestly take a look at a forty-year period with no criminal history or further interactions with the mental health system or criminal justice system,
I think the implication of the proceedings was that this was not true, clearly wasn't true, and the court didn't want to waste time and money on sorting it so used other procedural grounds to close the matter.
Most people who fail in these kinds of proceedings are so allergic to basic competence and not being an entitled asshole that nobody who actually witnesses the situation feels bad. In the same that you look at most police encounters and go: "Should he have beat his ass? No. Did he absolutely earn it? Yes."
Most principled third parties read about these situations and fear some authoritarian judge taking rights away (which does happen) but the vast majority is "please give me something, anything to work with.....okay I guess you won't."
Throwaway05
3mo ago
terrifying precedent
I was terrified when the democrats stopped listening to the court system (ex: gun control), ignored violent protests (BLM) and engaged in unprecedented law fare against individual politicians and an entire voting block (ex: anti-BLM, J6).
This is just more of the same or better than all that.
Throwaway05
14d ago
I think you can probably draw a line of separation between "normal" people who have personality traits, tendencies, hobbies, and political views I do not like and people who have severe mental illness (or an episode of the same with increased risk of recurrence).
Admittedly this guy was a lot further back so that the standards were different then they are today after some testing and improvement, but you have to work very hard to earn an involuntary stay and be very poorly behaved. Almost ALWAYS it involves true serious mental illness such and Schizophrenia, Bipolar disorder, severe Borderline, or MDD with suicide attempt or suicidal ideation. Or. It involves someone who is so unpleasant, uncooperative, violent, etc. that they are almost always a dangerous criminal they just might not have gotten caught yet (and the latter bucket is much less common).
If you are a threat to yourself or someone else in a real and foreseeable way you will likely be so again and the amount of danger is quite a bit higher. This is not "I dislike Nazis and they could do bad things!!!" this is "30% chance of murdering someone."
Throwaway05
14d ago
You have not proposed an alternative.
If your neighbor goes off of his medication and keeps following you around as you leave your house saying "Nybbler you raped me, I'm going to shoot you."
What do you want to do with this guy? Sure you could get him committed, but he'll be admitted, get stabilized, go home and go off his meds again and then go buy a gun and shoot you.
Especially in NJ the cops won't get involved because it is clearly a psychiatric matter not a criminal one.
Throwaway05
3mo ago
Die
Very funny Worf, eat any good books lately?
Throwaway05
15d ago
I will freely admit that sometimes places are a little "soft" with commitment (or lazy) but in general (and uniformly in busier places because resources are scarce) systems are very good at following the law, which varies by state by state.
In essence though the idea is the person needs to be a danger to themselves or others. The way that works out in practice is significant, imminent danger. You might say you have suicidal thoughts, but unless you have a plan and a situation which makes implementing that plan easy and likely then you'll get sent home.
When it comes to homicidal thought content its not "i'm going to kill my wife" its "I went out an bought a gun because I want to kill my wife because she is cheating on me" (and she is not in fact cheating, that's a delusion).
Putting aside the suicide end of things, you basically have to be having something (psychiatric) going on in your life that makes you likely to kill somebody. That gets taken seriously because a lot of these people don't get caught and end up murder suiciding, killing people, and doing things that end up in the news. Getting treatment on board or removing guns from the equation when they present themselves is huge.
The best predictor of future behavior is past behavior. Even with that in mind some people do get discharged from the (medical) hospital after a suicide attempt. When done properly (which is admittedly sticky) the burden for commitment is high. On the homicidal end of things you can credibly be planning to shoot up a school but if it's not psychiatric in nature...off you go (although some will make exceptions for this for the obvious reasons).
Inability to care for oneself is part of the assessment but that almost only comes up with people like chronic schizophrenics who can't feed themselves and so on.
Basically the idea is that (like with a felony) you've had an event that's so bad that it greatly contorts your actuarial risk of bad behavior such that abridgment of your personal rights is appropriate in order to protect others. That's fundamentally what a commitment IS, so taking away guns is not far off from a commitment itself.
Throwaway05
15d ago
Yes and just like queen mab,* contact with them can be quite hazardous.
I do enjoy the "deck the halls with beta blockers olol, olol, olol, olol" joke.
*Monoclonal antibodies (mAbs).
Throwaway05
15d ago
Okay let me actually think about this deeply and come up with what I'd consider acceptable policy.
I figure felony and involuntary commitment should be considered around the same in terms of severity (we'll come back to this).
This means default to no for gun acquisition for people in those categories. People deserve rights including the right not to be limited in their behavior when possible, however other individuals deserve the right to be free of molestation and incidents of bad behavior skyrocket once you look at the pot of the population that are felons or involuntarily committed. Schizophrenics crime rates are lower than many might anticipate but this is in part driven by underreporting and the most heinous crimes in society are committed by violent psychotics, both of those facts should be kept in mind.
Both involuntary commitment and felony charges get misused. Trump is now a felon. A patient who was diagnosed with cancer at age 19, made a credible attempt to end their own life in the setting of that stressor but then survives and has no further interaction with mental health care? Yeah seems like both of those shouldn't be limited.
Therefore there should be an adversarial process to get permission to own a gun again (like an expungement hearing). Yes this puts a time and financial burden on people to regain their rights but they lost them for good reason and the majority of people who go through either of those are appropriately labeled.
Okay so why does this guy not deserve his gun? Well: involuntarily committed. Reading between the lines looks like for good reason at the time despite his protestations to the contrary. Now he also appears somewhat disorganized, likely has mild cognitive impairment and has poor judgement (why was he not organized in his defense? Where's the lawyer? He admits he is lying to healthcare professionals...). It's not unreasonable to assume the guy is full of shit. Navigating expert witness testimony, dealing with HIPAA and subpoenas and all the good stuff is time consuming and expensive, likely it would establish that the guy was lying about ongoing psychiatric care and the reason for his admission, the judge skipped ahead and tried to look for a justification and found one. If the guy hired a lawyer he'd be fine.
For basic rights the idea is probably that both the responsible and irresponsible are supposed to have them (and that includes 2A even though the latter part of that scares people). But once you've gone through the first "hit" it seems reasonable to make the standard now be that you have to be responsible. This guy clearly fails to establish that he is now responsible.
Okay back to why Invol and Felony should be labeled as similar faults.
Maybe the best way to make this case is to look back at one of your other points: "Sure, who are the courts going to believe?"
Most medical schools give students a chance to witness (continued) commitment hearings during the psychiatric clerkship.
Here's how it goes:
Public defender: Don't talk. If you don't talk the judge will let you go.
Patient: Okay.
Judge: Let's begin, on the matter of...
Patient: I DO NOT RESPECT THE COURT'S AUTHORITY THE JUDGE WORKS FOR THE NORTH KOREAN GOVERNMENT AND HE RAPED ME LAST NIGHT.
Public defender: "..."
Their are absolutely doctors and facilities that are soft in their commitments but especially in large urban areas you'll see patients get discharged with situations like:
-"I'm going to go home and kill myself" (16 year old and parents say they can go home safely)
-"I'm going to shoot up the school" (criminal/police matter not a psychiatric one if no pathology is present)
-Patient who won't speak to anyone in the facility because they think everyone works for the CIA but takes steps to shower, eat, and sleep.
Involuntary stays are usually appropriate.
What complicates matters in the public imagination is that most conditions that lead to commitment involve some impairment of insight so when they complain on the internet they withhold details and context and make it seem like they were abused by the system.
Throwaway05
15d ago
I believe a normal person should not have their rights abridged.
However, I believe a convicted murderer shouldn't be allowed to have guns. That's pretty common sense (although I'm sure some disagree), in the same way that I am strongly pro-1A but don't want a nuclear scientist giving detailed instructions to ...certain kinds of people.
Some carve outs should be allowed.
Some people shouldn't own guns.
Another clear category is schizophrenics. Once you get the schizophrenia diagnosis (assuming it is well formulated, which it may not be) then you should never ever allowed to own guns because you don't know what is real and that makes you a huge risk to yourself or others.
If you are involuntarily admitted to the hospital that means at some point you were a imminent serious risk to self or others (thats more or less the commitment criteria in most states), and while some people have one episode and then they are done, generally that is not the case. The risk calculus is instantly much different (sidebar: if you believe people have a right to end their own lives even when they have a potentially modifiable medical or psychiatric condition then this changes the calculus significantly).
While they do get it wrong some times the vast vast majority of committed people have some combination of a. incredibly serious mental illness. b. credible suicidality or homicidality. c. are an absolutely enormous asshole.
Society is almost certainly better off restricting the rights of those three kinds of people and doing so results in less death and crime.
Important to note is that you can sue for inappropriate involuntary commitment and that this is a major cause of malpractice claims. The opportunity to defend yourself from malfeasance is there. Yes psychiatrists have notoriously cheap malpractice insurance.
Throwaway05
27d ago
Somebody on here was reading Sublight Drive, which I have now finished and loved. The author reported he had to stop writing secondary to mandatory service, anybody know what country he is from?
Throwaway05
15d ago
Commitment hearings are tricky, often there is some type of collusion between the judge and both lawyers. This is because 99/100 the situation is super obvious.
I imagine (as RovScam points out) that the everyone involved quickly identified this guy as a full of shit asshole and they went this way to avoid wasting everyone's time.
It isn't great - and I'm a very strong 2A advocate, but when you see the circumstances that result in admission you realize almost nobody who has been involuntarily should be allowed near a fire arm.
It's like prison. Are some people in prison under false pretenses? Sure. Do they almost all clearly deserve to be in prison. Yup, and it's obvious after five minutes working in a forensic setting.
Throwaway05
1mo ago
I mean, plenty of insane bad drivers out there, but the difference between those and some of the cyclists is something else.
Throwaway05
1mo ago
Again, the ability to walk around with a general prescription that can be used at any pharmacy is the default state - in essence it has been removed by regulatory burden and corporate oversight.
No reason it can't come back other than those things (and plenty of doctors are still able to prescribe via paper).
Take it up with the government.
Expanded OTC formularies are something that can be done in different cultural milieus but is simply incompatible with America. Too many people would kill or harm themselves or others. The costs and externalities are too high.
Throwaway05
4mo ago
Actual quote from my last time talking to a patient in the ED:
"A shelter, why the fuck would I go to a shelter doc? It's fucking filled with homeless people, besides they won't let me get high on crack!"
In order to fix the problem you need to be willing to violate some people's rights and to discriminate, the former is something that you do sometimes see flexibility on in the left but the later...
Throwaway05
4mo ago
Two case studies in government waste:
As you can likely imagine right now a lot of people in medicine are sharing tales and taking sides in the great DOGE debate. Two that popped up on my radar and stuck out to me:
- One of my medical school classmates is a psychiatrist at redacted city hospital. He has been informed that the state Medicaid will no longer pay for psychiatric emergency room visits if the patients do not go to their aftercare appointments within 30 days. They have been informed that they could lose their government funding if enough patients fail to do this.
Some problems: -As an emergency room most of their patients have no insurance or Medicare or Medicaid, meaning the facility often get paid less than cost. They only stay open at all because of their state grants.
-Many of the patients are drug addicts or malingering (because of homelessness for example). Every day you’ll hear something like “you’ve been here every day for the last three weeks” or “have you considered stopping using PCP? You always seem to fight with the police when you do” and “here’s your follow-up appointment, will you go? No? Fuck me? Okay thank you have a nice day.”
-Many of the patients who do actually have mental illness are in denial about it, or have some sort of limitation that prevents them from attending aftercare appointments.
-The “best” solution is probably to violate patient rights and involuntarily commit them to make someone else be on the hook for making sure they go to their aftercare.
-In the meantime, the hospital has hired several additional staff to manage some of the administrative complexities associated with this change (for example hammer calling the patients to remind them to come to the appointment). They have also hired night staff whose job is to sit in an office overnight purely to schedule appointments with an outpatient program (otherwise no patient could be discharged overnight because they wouldn’t have an appointment to go to…).
- One of the residents I mentor is about to do a rotation at the VA. This is pretty common for residents. His rotation starts in a few weeks. A few months ago, he got an email that included the instructions “it is imperative that you start your onboarding process for the VA right now otherwise your onboarding may not be finished by the time of your rotation” and “it is important that you not start your onboarding right now as it is too early to start onboarding and your onboarding may not be valid if you complete it too early.” This is not a joke or an exaggeration.
Anyway, he dutifully completed his requirements in a timely fashion (which were all pointless! Ex: what is the motto of the VA???). So, months later his rotation is starting soon. He begins the process of emailing the education team once every 2-4 business days. You have to email them multiple times before they respond. The conversation goes something like this over the course of multiple weeks, “I think I’ve completed my onboarding do I have to do anything else?” “no” “okay is my onboarding done” “no” “okay when can I pick up my ID card” “when your onboarding is done” “I thought my onboarding was done” “yes” “okay what I am waiting on” “nothing.” I have seen the emails; it really looks like this.
At this point his program tells him to CC the chief of medicine at the VA hospital, at which point the person responds with “okay we put in a ticket for this a month ago, your training is complete but your training is marked as incomplete.” A screenshot has been attached that shows the request and an automatic response that says something about high ticket volume and that they will get to it at some point. The chief of medicine replies “….does the trainee need to do anything?” (we are here).
The resident will be able to rotate but will not be able to do any work without computer access.
It’s worth noting that the VA is paying for this resident to be there, despite the fact he will in fact not be able to do anything. At his last VA rotation (yes they go through this for every resident every time) he was six weeks into an eight week rotation before he got access.
Throwaway05
29d ago
Proceed in an orderly and predictable manner
Personally I think this is an underrated component of the whole thing, and part of my issue with Bikes. Being predictable is safe.
Throwaway05
11d ago
The process is somewhat individual and adversarial. In NJ the way it works is more or less this - somebody has to be concerned about the patient (usually a family member, a concerned bystander, cops walking by) the patient is then taking an ED or Crisis Center on a temporary hold, at which point a social worker has to see them and think they need to be committed at which point they are seen by two physicians who have to feel it is appropriate. Individuals involved can be sued, fined, lose their license for abuse and so on. Then afterwards there is an expungement process. If the patient is held for an extended period of time without discharge then they have a formal court hearing that can and will result in release from the psychiatric hospital.
Obviously there is some abuse and laziness in the process, most typically the second physician would be like "eh I wasn't there, I'll assume the first doc was correct."
Ultimately this involves multiple trained professionals with skin in the game to make the determination that someone needs to be committed and they can always go through a court process afterwards.
I think some of the value here is that most people who end up committed don't have the functional status to do much of anything. If you make it opt-in most wouldn't, and wouldn't be able to get expunged. I'm fine with a more robust way of people getting their rights back but it has to be done in away that isn't too egregiously expensive and defaults to no because of how dangerous a small subsection of these people are, which is hard to convey if you've never seen them.
Crisis centers do occasionally catch people who will explicitly say that they are interested in killing people (in a sociopathic way) and loading them down with rights restrictions before they get started in an unalloyed good.
Hope all of that makes sense, typed fast.
Some other stuff: -While most doctors aren't anti-gun they aren't committing people purely to get them away from their guns unless the doc has concerns for threat and its therefore appropriate. This is because these settings are overworked, their aren't enough beds for those who really need them, and the hospital doesn't get paid if the insurance company doesn't think the patient actually needs to be committed and that rolls onto the doctor's head. In the worse case scenario no psychiatric hospital will take the committed patient because they clearly don't need psychiatric care and then the ED comes over and stabs the psychiatrists 80 million times for taking up a bed while someone is bleeding to death in chairs.
-Average disorganized street homeless person is harmless other than the inability to care for themselves even if they are vaguely threatening, so they tend not to get taken in unless they are actively harassing someone or committing some other crime like trespassing.
It's usually more like "do you have any medical problems" "no" "any history of heart disease, high blood pressure, diabetes?" "no" "what are these scars for" "Oh I had a triple bypass in 2003 and I'm on 8 medications for all that."
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