I'MMA LET YOU FINISH
The goal of deinstitutionaliztion is noble, if a bit squishy around the edges when it comes to rhetoric. Working in this field I treat a lot of folks outpatient who previously would have been committed to hospitals easier and for longer stays. But you are right, all the philospohical posturing aside, the availability of treatment is inadequate either inpatient or outpatient, and money is a big factor. Liberal or conservative, state governments have been squeezed, and certainly maintaining large, expensive inpatient institutions have been prime for the chopping block.
Shockingly reasonable? I have to disagree.
"The severely mentally ill refuse treatment simply as part of their illness. The only answer is to treat them involuntarily, and there is a budding trend toward this solution in state laws."
The idea of anyone being forced by state law (or federal) to receive unwanted medical treatment seems rather dicey for me, but I'm doubly wary of forced treatment for mental illnesses, the majority of which cannot be diagnosed or quantified by any concrete test your doctor could give you... only by observation of symptoms.
(At least this is my perspective on the issue as a Biology major in college)
For something completely different between the loss of rights entailed in having your brain chemistry - the sum of your thoughts and memories, altered against your will, think of the precedents laws enforcing treatment for mental illness could lead to...
It would certainly bolster the school's right to demand children be given ritalin and other drugs over their parents and doctors wishes...
Jicklet,
The other side of the coin is all the people who want help and can't get it. Back in the day when I had health insurance, I got 30 days of inpatient care for psychiatric illness. 30 days over my whole lifetime. For anyone who is seriously ill, this is a joke.
The forced treatment of mental illness is such a difficult subject but it really should be an absolute last resort. I once had to consider the institutionalization of one of my siblings and it was agonizing. We opted to wait and we were able to convince her to take medication voluntarily but it was scary, because she was letting herself be abused. The formerly institutionalized are now by and large elderly. But one of the main effects of the move from institutionalization (as well as deservedly greater attention to civil liberties)was to create a generation of mentally ill who never became "used" to the idea of institutionalization or complying with an institutional regime. This makes them much more difficult to treat, in addition, they are more likely to complicate their picture through "self-medication," with drugs like Ecstasy. Although I am not the biggest fan of pharmaceuticals, the real promise in this area lies with new ways of delivering proven psych drugs that have fewer side effects (e.g., transdermal patches deliver the drug for a week at a time). The weekly dose means that the patient doesn't need to be constantly badgered to take meds and delivering the drug through a patch doesn't bombard the bloodstream the way daily doses do, lessening the likelihood and severity of side effects. But there's no doubt about it, some people like themselves better when they are ill. This is a hard thing for us "sane" folks to understand and except.
The idea of anyone being forced by state law (or federal) to receive unwanted medical treatment seems rather dicey for me, but I'm doubly wary of forced treatment for mental illnesses, the majority of which cannot be diagnosed or quantified by any concrete test your doctor could give you... only by observation of symptoms.
Sorry, but forcing treatment on those who are mentally ill is sometimes a necessary evil. As someone who has a schizoprenic family member (and a couple severely clinically depressed relatives), I know this all too well. There are people who are a demonstrable danger to themselves and others and you must do something. When somebody, say...starts believing that their mother is trying to poison them and glues the fridge door shut to prevent it, is destroying property, and starts threatening people, the difficult act of committing that person and getting them treatment is the only recourse. People in this situation don't know they need help because they are so divorced from reality.
And Barbara, I'm with you. I'm uncomfortable with "better living through chemistry" on the one hand, but there has been a lot of great progress in dealing with the organic causes of much mental illness.
For more information, check out:
* http://www.nami.org/
* http://www.narsad.org/
Sorry, meant to put a little more info about the websites in that last post:
* NAMI is the National Alliance for the Mentally Ill. They deal with policy, advocacy, education, family support, etc.
* NARSAD is the National Alliance for Research of Schizophrenia and Depression. They're a donor-supported research organization.
I'm with Ntodd and Barbara on this one. I have a manic depressive relative whose behavior has been devastating to his whole familyh and especially to himself. In theory I'm as suspicious of government and of medicating people against their will as the next person but when you come down to actual cases you find that there are large numbers of people who really need help and can't get it. Yeah, some of it is money and treatment up front before people get desperate enough to go off their meds. Unfortunately, those services are almost non existent except for the wealthy or heavily insured working middle classes and even for them the services are spotty and hard to find. Once people go off their meds and fall out of the system (lose their jobs, become violent or delusional, become homeless) it may be too late to reach them with anything but the kind of committal procedures (and hospitals) that no longer exist. Its terribly, terribly hard for people to come back once they've burned their bridges behind them through years of irrational and dangerous behavior. I actually think most cases are more clear cut (could be handled by family members, doctors, and judges) than murky.--aimai
I know from second hand experience that some of the severely mentally ill who are a danger to themselves and others have been deinstitutionalized to group homes where they are...a danger to themselves and others. How can the resident supervisors prepare their capable clients for life in the greater community when every pop can, paring knife, and key must be locked up to prevent one client from cutting themselves? Medications don't help everyone and genuine psychiatric care is hit-or-miss at best.
Just want to point out that many severely mentally ill people are still institutionalized in this country, in even worse conditions and at greater taxpayer expense than before. They're not in mental institutions anymore, they're in prison.
Deinstitutionalization may have its intellectual origins in liberalism, but its implementation was thoroughly Conservative. As governer Ronald Reagan lead the effort to close down State Mental Hospitals, and accelerated the movement as President. Try a Google on "Reagan Deinstitutionalize".
Funny thing though, the follow up funding for community care never seemed to come through.
Beth, that is such a profound point. It makes me by turn angry and sad that our awareness of mental illness is still so benighted. Clearly, looking at the Andrea Yates case and others, without prejudging the outcome, there should be a serious effort to update criminal concepts to reflect what has been learned about mental illness in the last 100 years. (Most criminal law concepts on culpability and mental illness predate the 20th century.)
Try this link found via the search Reagan Mental Hospitals.
Note that it starts from a post defending Reagan.
http://www.health-and-
medical.co...g_msg1686.shtml
Well that didn't work. Cut and paste time or maybe:
Its Ronnie
Any HTML gurus out there? The link was apparently truncated by the first "-", both times. Feature or bug?
Medications these days are wonderful, but schizophrenics can still hear voices on Risperdal, for instance.
I'd argue that a mentally ill person who is a danger to themelves or others can be treated involuntarily as can another person in that situation. Until then, I object to involuntary treatment. It is involuntary. Which is a shame, because many mentally ill people are happier once they've had involuntary treatment and are on their meds. Then they go off their meds again.
Thanks for pointing out the cynical role Drooling Uncle Ronnie played in all this.
In a karmically-perfect universe, he'd be roaming the streets like so many others he's directly responsible for. Guess I'll just have to hope he burns in the afterlife... and of course, gets to see me piss on his grave.
i smile to know he is in a hell right now, too bad he doesn't realsie it.
"Demagogue links to this shockingly reasonable article by Rich Lowry about the mentally ill."
Lowry's article isn't reasonable at all. For reasons that I describe in the comments on the Demagogue site.
I am a bit of a lunatic myself sometimes. Aren't we all? (Will anyone seriously answer "no" to this? If so: how boring. Smoke some pot at 6:00 A.M. and go to your local KKR-mart for a frozen pizza and you'll quickly see what I mean.)
I don't think we lunatics want to be treated against our will.
At least not until society is sane enough that making wars that blow people's arms and legs off in order to keep oil companies and arms dealers in the pink is regarded as at least as bad a thing as hearing voices that turn out to be the neighbor's TV set. Otherwise it is hard to have confidence that the new state of mind is going to be much of an improvement.
O. Bender:
"All are lunatics, but he who can analyze his delusion is called a philosopher." - Ambrose Bierce
Great quote, NTodd. Thanks.
A few years ago,I picked up a hitch-hiker in the diciest neighborhood in LA - a beautiful, young girl (red hair, huge brown eyes, long and delicate body). She said she was a dancer and was on her way to New York. The conversation paused as I was pondering where and how I would let this beautiful child out of my car, when she turned to me and said, "Cubism is the slave of nature, don't you agree?" Well, I know schizophrenic poetry when I hear it.
I talked her into giving me her mother's number and called her to let her know where her daughter was. The young woman was schizophrenic and because she was a dancer, she refused to take her medicine because of the way her ability to move was affected. Of course, without the medicine she was unemployable.
Because she cannot be hospitalized against her will, she never had the opportunity to stabilize and medication to be adjusted so that she could continue to dance.
Perhaps what we need is a middle ground where people can be hospitalized for longer periods so that medications can be adjusted and stabilized. So that they have a chance at learning how much better their life can be if they just take those infernal pills they hate so much.
But Cubism IS the slave of nature. 
I agree. When was the last time that the third sentence a complete stranger uttered to you was a question of this nature? Schizophrenics have a poetry that is all their own.
My husband (a professional writer) has a college acquaintance who is schizophrenic and also one of the most dazzling writers I've ever read - when he's on meds. When he isn't on meds (which has been for the past 15 years) he is capable of sending every day for weeks on end, 50 - 60 handwritten pages, perfectly spelled, flawless grammer, completely entertaining. It's mind boggling to get these letters day after day and wonder what the man could do if he'd just take his damn meds.
But he believes that the people trying to talk him into taking his meds are trying to rob him of his talent - and of course, he writes just as well (although not quite as obsessively) and is frequently published, when he takes the meds. However, without that, what he writes is obviously the fantasies of a mad man.
He can't hold a job, he moves on and off of public assistance and his life is a waste. In the past, once stablized, he's stayed on the medication for years. But now, because he isn't violent, there is no intervention. It's all very sad.
Lorelynn, I have been trying to help a secretary in my office deal with a similar situation involving her son, a florid schizophrenic who is extremely paranoid. He has always refused to take medication, his condition has deteriorated over the last five years. I agree about the necessity of a middle ground -- a six month window, perhaps, where someone could be stabilized. But you cannot rely on drugs alone, because one of the major factors underlying compliance is building insight into a person's disease, which is something that many people resist. No one wants to think that they are out of touch with reality. As to those who blithely pick up the R.D. Laing sound alike statements, it's not about whether the so-called sane do things that don't make any sense, or that are evil or misguided, it's about whether your thinking is totally disconnected from reality. My sister used to listen to the radio in order to decode the messages her "boyfriend" was sending her, and allowed herself to be sexually abused by a man who was clever enough to pass himself off as her "boyfriend's" double because he couldn't be there. These were things that SHE NEVER WOULD HAVE DONE in the absence of disease.
I think that the tenor of the conversation over forced institutionalization would change significantly if the target was given the same rights as an accused criminal - after all, it seems that there should be someone to speak for that person, since if 'convicted' they're going to be without freedom or free will and forcibly drugged for the rest of their lives, if their doctor so chooses.
It's a hard subject, but I'm not comfortable with the idea that people who oppose forced institutionalization are against helping the mentally ill. The idea gained steam when people started to get a look at what was happening to the institutionalized mentally ill.
That it was co-opted by right-wing government googoos looking for programs to defund doesn't change the very real stumbling block that right now, people in the charge of our government have very little defense from our government.
I think it should be hard enough to get someone institutionalized involuntarily and keep them there that the case for doing it would have to be bulletproof. We are talking about lives.
In a caring society, we would not expect one solution to solve a wide variety of problems. Only in this one do we accept more testing as a solution for increasing academic performance. (I've have to say that everytime I hear of those kids spending more and more time preparing for SATs that they now take over and over again, I can't help but wonder about all the books they could have been reading and getting an education from.)
Of course it all really comes down to finding the cheapest solution. Close the big institutions in favor of "group homes" that just never managed to get built. If they could only convince those parents that we need to tear down the public schools before we give those school vouchers, the crisis in education would be solved. The Cheapskate Conservatives are always surveying ideas from the left that they can sell on humanitarian grounds but really use to reduce social spending.
NTodd and Barbara, I couldn't agree with you more.
I myself have had clinical depression most of my life, although it wasn't properly diagnosed as such until my early 20s. For the past decade, I've been off and on a series of medicinal coctails just trying to keep the wolves at bay.
Thankfully I've hit on a combination of three drugs that allows me to get out of bed, hold a job, and live a somewhat normal life. Once this new regimen fails (like they all do, eventually), I'll probably have another collapse and be off work for another few months while the doctors 'experiment' with something else.
I have had instances where I've been completely out of control of myself, due to the depression and the anxiety it brings. I've not been able to manage my money, go to work, or leave the house. I have not had to be hospitalized, mainly because I have a very loving and supportive wife and family.
However, there's many out there that are not as fortunate as I am. Some of them truly need to be institutionalized at some point in their lives. My wife's best friend has a brother with schizophrenia who was in just that situation. His behavior, while not illegal, was erratic and disturbing, and he wasn't able to function at all. His apartment was a mess, he didn't bathe, he couldn't work, wouldn't take his meds-- nothing.
These people, while not technically harmful, need some sort of intervention. Unfortunately, most of them will not go voluntarily. It's a very tough situation but is oftentimes institutionalization is a last resort.
And no, mental illness is not funny. Yes, we all get a little "crazy", but smoking a bowl and bogarting the Doritos is a friggin hayride compared to being completely hopeless and on suicide watch.
One out of four families in America have someone who is mentally ill. It's time we started treating it like the disease it is, instead of trivializing it and those who live with it daily.
Julia, for all intents and purposes the involuntarily committed are given the same rights as the criminally accused, with the possible exception that the standard for proving "guilt" (don't know how else to say it) is not beyond a reasonable doubt. There is a SCOTUS case that states that the standard must be at least as high as clear and convincing evidence, but considering that the inquiry is not as factual as that of a criminal trial, the beyond a reasonable doubt standard was deemed not necessary (though a state could use it).
Marie, because institutions often did not provide the care that they were supposed to, it was relatively easy, politically speaking, to discredit them rather than to make them better and more responsive. There also were many people who were inappropriately committed, for mental retardation, for instance. It was an unfortunate confluence of cost, social trends (R.D. Laing, for instance) and civil libertarian concerns that, all of whose adherents, when it comes down to it, had little interest in pursuing alternatives for the truly mentally ill. Does "Titticutt Follies" mean anything to you? It was a documentary about an incredibly inadequate state psychiatric facility in Massachusetts.
CP - I'm glad you've found a good mix of meds. If you don't mind, what three are they? One of my relations is on a cocktail themselves--just wondering if new research has found something.
I was undiagnosed as clinically depressed for a decade, and took prozac for 1 year. I've not taken it for several years because some studies have shown that in certain cases (such as mine), taking the drug along with what amounts to practicing positive behavior in the context of therapy can actually allow a person to "learn" how to not be depressed. Turns out the habituation takes hold after about 6 months of being on the medication. I was able to go off Vitamin P and am glad to no longer have to suffer dry mouth, crappy sleep patterns and the other side effects. Other family members have not been so lucky.
One thing that's important to understand about treatment is that people often start to really feel better because of the meds. Once they feel "cured", many people stop taking the drugs because the side effects do suck, the stuff is expensive and hey, if you're all better, why bother? That's a great danger, and I've seen this dreadful cycle play out a number of times.
Dunno if it will help, but doing what CP said and recognizing we need to view mental illness as treatable disease is important. The stigma is slowly lifting, but a lot more education is needed.
It seems clear that everyone here wants the best for the mentally ill. However, what behavior from a friend, family member, acquaintance or complete stranger determines when it is time for involuntary treatment? This generally means physical force. Must they be unhappy, or can they just be happy in a way that doesn't appeal? When in your personal behavior would you feel ready to be seized and hospitalized against your will? I find this question important, and neglected here, and I think most of us would like that bar to be set high. I set it at the threshold of danger to self and others. If I want to get an insane person to do something, I will try using reason as with other human beings and citizens, and as I'm sure everyone in this thread has. I will not move from that to force. This POV seems worth stating, since I haven't really seen it mentioned here. People have rights.
One problem that isn't discussed nearly enough is NIMBYism. When the funds are actually there it can still be impossible to open a facility because people are afraid of having "them crazies" in their neighborhood. The matter isn't helped by the fact that they continue to release sicker and sicker people into the community. It's an unpleasant fact, but there are people who have no business being out in the community.
The dangers to the unmedicated mentally ill go beyond what other posters have already listed. These individuals very often have on-going,life-threatening physical illness directly related to their psychosis.
I when I worked in a half-way house, we had two residents whose teeth were in such terrible shape that they had constant abcesses and were being treated with almost constant courses of antibiotics. We were lucky enough that we were able to convince one patient that he would feel better if he went to the dentist - he had the remaining stumps of his teeth removed, the abcesses cleared up and is complextion turned from greyish to a healthy pink. He had less headaches and had more energy.
The other case was not so great - he had been taken to court by his conservator in a last-ditch effort to force him to get dental care but the judge ruled in favor of the client. He continued to suffer pain, abcesses, headaches and probably will for the rest of his life, if the infection doesn't become systemic and his internal organs fail first.
John: part of the problem of schizophenia is that afficted persons are not very good at linking cause and effect. They might realize that they smell bad, but their mind doesn't make the connection between B.O. and lack of bathing.
They might feel overall contentment but aren't able to figure out that the alienation they're experiencing from other people, something they're not happy about, could be in part addressed by getting in the shower, wetting themselves, rubbing a bar of soap over themselves, rinsing themselves in the running water, drying themselves off with a towel, putting on deodorant and dressing in stain-free, freshly laundered clothing.
If an individual is that impaired, I don't care how content they are or how low a risk they are to themselves or others, they need help whether or not they recognize or not.
A big part of the problem is that the health and social service agencies that serve the mentally ill are overloaded. A doctor may have so many patients that it is simply easier to prescribe whalloping doses of meds than to take the time to work with the client to find a med regimen that works for them. Clients feel like shit, stop taking their meds and end up in the hospital with another series of health care providers who overmedicate them to keep them quiet and compliant, and on and on.
John, yes, that is really THE question. "Danger to self and others" has typically been interpreted as immediate physical threat to oneself (suicide) or others (clear threat of violent behavior). Most schizophrenics and certainly most depressives or manic depressives will never be a threat to others. And even for those who might, what happens now is that there is very little space between "imminent" and "actual" threat, and as Beth stated before, at least as many people end up in the criminal system as receiving psychiatric care when it might have done some good. There is virtually no mercy in the criminal justice system, even for the grossly mentally ill. We have to accept that there will never be an exact line, it can't be because of the nature of the inquiry. But the line now leaves a lot of people in a state of permanent psychosis. Several thoughts:
Threat to self should include ongoing and serious threat to physical and mental well-being: when you walk around city streets at night and let homeless drug addicts paw you because you're too scared not to (what my sister did), I think that should count.
When I say 6-month trial of forced treatment, I don't mean that this should be something that can happen over and over again or that it would ever be the first choice. It should be the last choice. And at some level, I believe, some people may really not want help, but all too often people don't want help because they have no idea that they can be helped (depression) or that they need help (schizophrenia, bipolar).
The biggest problem faced by those working in the state mental health sector right now is increased pressure to over-diagnose, in order to ensure that patients receive some treatement, even if it's way over the necessary requirements.
That's because the states' budget crises are leading to massive rollbacks of mental health provision. You still have the forced-care institutions, but nothing in place to help with the transition back to the community.
So, anyone working in the sector has the unenviable choice between letting people go untreated, or classing them as schizophrenic/psychotic/dangerous/incapable so that they receive some treatment, even if it's less-than-appropriate.
Just to back up what Bruce Webb said: while the principles of deinstitutionalisation were liberal -- read about RD Laing's attitude -- the implementation was fiscal-conservative. Thatcher's 'care in the community' was a massive deception: the 'community' which received most of those turfed out of mental institutions was the community of the homeless. (Thatcher, after all, said that there was no such thing as society.)
R.D. Laing discounted traditional notions of mental illness, for good or bad, calling into question the whole idea of *treatment*
Civil libertarians were shocked at the ease with which mentally retarded or only slightly ill, or not ill at all but weird people could be committed.
Both of these themes were pretty well encapsulated in the book and later movie "One Flew Over the Cuckoo's Nest."
So if most people are either there inappropriately or don't really need treatment . . .
I know it wasn't presented that way, but that was the cultural context in which de-institutionalization occurred. Which means that the budget cutters didn't meet nearly as much resistance as they otherwise might have.
Warehousing mentally ill people without treatment is wrong whether it's in prison or hospitals. I don't see any improvement for the next 5-10 years unless drug therapy gets much better with fewer side effects. It's a depressing situation.
Barbara: "all too often people don't want help because they have no idea that they can be helped (depression) or that they need help (schizophrenia, bipolar)."
Very true. And I'm glad your sister accepted help in the end. I like your compassion.
before i got into what im currently doing for a living, i worked at an urban state mental health hospital as a psychiatric technician ( i.e. orderly) for 2 years...
my aunt was a training nurse there and got me in...i had dropped out of college and was trying to put things back together economincally
our hospital was a M*A*S*H unit...for the indigent, alcohol and drug clients...and the tank when the police ran out of room in the jail on weekends...
most of the cliests were cool...but we had the occasional dangerous criminal on the locked floor where i worked...
i got kicked, scratched, cursed out in the most elequent of ways...and was damn lucky that i was able to get out and back in college again...
i worked full-time and tons of OT...and my yearly pay was roughly $12,000+/year...
thats right...$12,000/year for one of the most demanding and emotionally draining jobs one can get...
and this was a state salary...
in the mental health field, you truly get what you pay for...
lack of money hurts the clients...and severely reduces the quality of health care worker both in hospitals and in group homes...
with a brother who is paranoid schizophrenic and another who is autistic...my family and i have done everything we can to keep them out of long-term hospitalization...based on my experience...
the way this country treats its mentally ill clients is shameful...truly shameful...
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