Ode to Bob
First off, this isn’t really an ode. I don’t know why I chose that title, other than it satisfies a certain need for perverse irony I feel when I’m angry about something. I started writing this piece several months ago and then quit because I was too angry to write about it. I’m still angry, but it is far enough away that I think I can get through it. Second, there is no Bob, or at least that’s not his real name. Bob is just the generic name I use when I can’t think up anything catchy. Keep in mind that while in some respects I am talking about society in general, I am most concerned with individuals who end up in my facility. Also, I had intended to post this in multiple parts, but I’ve got it done, I’m having trouble with the “cut and paste” from Word Pad, and I’ve got the time to mess with it right now so you get the whole thing.
Recently we had a mentally ill client at our facility. Actually, we had (and still have) several. Bob was sort of a microcosm of the main issues we are dealing with when we have mentally ill clients at the facility. Bob was’t the brightest guy around, but his intelligence was more than adequate to be functional, and certainly sufficient to get him into trouble when he t ried to be sneaky. Bob was in the system and in our facility in particular because he had committed a few relatively minor crimes and had a history of violence. It was really a very simple deal. All he needed was regular medication and qualified trained individuals to work with him on dealing with his illness.
Bob went to jail. This happened for several reasons. Among them, we couldn’t get professional assistance to stabilize and monitor his medications to see that they were working. The local Mental Health Department couldn’t or wouldn’t provide services to him. They kept promising assistance to him and then kept rescheduling his appointments. (We have documented a certain reluctance by mental health professionals in the community to work with potentially violent clients. Now they would never come out and say they don’t want to work with these individuals because they are afraid of them, and I would never openly accuse any of them of being cowards, but, it is surprising how effectively an individual can be excluded from basic mental health services if there is any hint of a history of violence in their past.)
Eventually, Bob got frustrated. We couldn’t let him leave our facility to live in the community without medication, programming and housing in place and he couldn’t get any of those things. As he grew more and more frustrated, he eventually got to the point that he was unable to maintain control of his own behavior. (Of course we will never know if it was simple frustration or whether his medication was not working.) He eventually threatened another client and had to be sent to jail. Now it may be that Bob isn’t really a very nice person and he may, in fact, deserve to go to prison, but I don’t know that, because we never got a chance to see whether he would take responsibility for his actions because we never got to see him function under the influence of stabilized medications. Because of Bob, I came face to face with the nature of the beast, so to speak.
THE NATURE OF THE BEAST
In the middle part of last century, mentally ill people went to the hospital. Asylums, Sanitariums, State and private hospitals, and there may be more names I’m not familiar with, but still hospitals in some sense of the word. I vaguely remember the social stigma attached to being crazy in that time. You sent your crazy relatives to the hospital “for their protection” but that was code for “so they don’t cause a scandal and embarrass us.” There were well over half a million people in state mental hospitals in 1959. Based on a population of over 177 million at the time, that was roughly 0.3 % of the US institutionalized due to mental illness. The shift to “de-institutionalization” had dropped the public psychiatric hopital population to around 70,000 by the late 1990′s, or roughly 0.02% of the current US population.
“De-institutionalization” came about for a variety of reasons. I think part of it was due to the general social climate. As the sixties moved on, it was less scandalous to have a crazy relative. After all, how scandalous could it be when there was rock and roll, hippies, drugs, free love, psychedelic everything, including art, music, drugs and clothes. There was also a growing perception that psychiatric hospital were problematic. In the public mind, hospitals became equated with human warehouses, where there was minimal upkeep, because all the patients were heavily medicated, drooling zombies who spent their days doing the “Thorazine shuffle”. Hospitals were also expensive. Even if they are nothing more than human warehouses, they still take a lot of staff to operate.
The answer apparently seemed obvious. We would provide care in the community. It would be less expensive, more humane and the patients would be able to lead more fulfilling lives.
Well, I think it is safe to say that it didn’t work out to be the Mental Health utopia advocates envisioned. First, community programs were never sufficiently funded. Second, mental health advocates assumed that mental health patients in the community would have access to appropriate medications and that they would take them. Sane, rational people have trouble understanding that if you think you are Jesus Christ or you think God is talking to you, you probably don’t think you need medications. (I realize that that was an overly dramatic statement. Most mentally ill individuals don’t think they are Jesus, but the point is that one of the features of some mental illnesses, especially schizophrenia, is the lack of insight into the disease. In other words, you don’t know you are sick. And if you don’t know you are sick or don’t believe you are sick, why would you take medications? Especially ones that tend to slow you down and make you groggy, which most of them do, to one degree or another.)
The third major problem was that: “Advocates assumed that mentally ill individuals would voluntarily seek psychiatric treatment if they needed it. As it turned out, about half of the patients discharged from psychiatric hospitals did not seek treatment once out of the hospital. Many of those who suffer from schizophrenia and manic-depressive disorder do not believe themselves to be ill. These untreated individuals constitute most of the mentally ill population who are homeless or in jail, and who commit violent acts.”(source) And that is the error in thinking that is most relevant to my work, that mental health advocates somehow forgot or ignored the fact that some mentally ill individuals are violent, especially when un-medicated.
THE RIGHT TO BE CRAZY
Apparently we all now have the right to be crazy. And that right was established for us by out friends, the lawyers. In essence, a series of legal rulings have established (generally speaking, of course) that you can’t compel individuals to medicate themselves and you can’t intervene until after they have done something violent. There are laws in some states that provide for “outpatient commitment” requiring a mentally ill individual to take medication in order to stay out of the hospital. However, “Lawsuits brought by the American Civil Liberties Union and Washington-based Bazelon Center for Mental Health Law have changed most states criteria for outpatient commitment. Individuals must be classified as an imminent danger to themselves or others before they can be involuntarily treated, either in the hospital or in the community; this criterion is strictly applied. Most psychotic individuals, who are merely making threats against others or living on the streets and eating out of garbage cans, are not deemed legally sick enough to qualify for outpatient commitment.”(source)
WHERE DO THEY GO?
So where are all those violent mentally ill individuals? Eventually most of them end up in the legal system. While making threats against others isn’t sufficient grounds to get you the help you need (whether you want it or not) it is against the law. “Bureau of Justice Statistics for midyear 1998 reported that an estimated 283,000 mentally ill adults were incarcerated in the nations prisons and jails, and another 547,800 adults with histories of mental illness or treatment were being supervised on probation.3 Nearly one-third of mentally ill offenders in the study also abused alcohol (a “dual diagnosis”). Growing numbers of mentally ill offenders have strained correctional systems, which are not designed or staffed to manage them.” (source) (I might point out here that “dual diagnosis” is not the current euphemism of choice. Now the buzzword is “co-occurring disorders”.)
Because we won’t deal with the problems of the mentally ill, either in the community or in appropriate institutions, violent mentally ill individuals end up in the Courts. A basic principle of the Adult courts system is that the Court should do what is best for the community (as opposed to the Juvenile system, where, due to a perceived lessened degree of responsibility due to immaturity, the Court is supposed to do what is best for the juvenile.) Violent mentally ill individuals throw a huge monkey wrench into the Adult court system. Few judges are willing to hold mentally ill individuals fully accountable for their actions due to a perceived lessened degree of responsibility due to their illness.
Judges, then are faced with a nearly impossible task of appropriately sentencing violent mentally ill individuals. Sending them to state psychiatric hospitals is generally not an option, as many state hospitals won’t accept violent mental patients (yes, I know that sounds ridiculous, but at least in this state, it is true) or will discharge them within a few days (after medicating them) because they are no longer a danger to themselves or others while medicated. Judges can’t ignore their responsibility to the community. They just can’t ignore the potential danger to citizens. Yet, they can’t ignore their responsibility to taxpayers, as it is expensive to send violent mentally ill persons to prison and most of them don’t need to be in prison as long as they are medicated. (see a pattern here?)
Judges often try to put violent mentally ill individuals on probation. When this happens, they usually order the individual to participate in mental health counseling. (Which may not be available, or they may not be able to pay for, or which they may not qualify for, because they are 1) violent or 2) a criminal. As I alluded to earlier, one could come to the conclusion that mental health service delivery systems only want to deal with “nice” crazy people.) Judges also usually order these individuals to take medications as prescribed. Except that they may not have access to the medications (because they usually don’t have a steady income and are not likely to maintain employment without supervision) and even if they have access, they may not take regularly (either because they are not capable of maintaining a regular medication routine or because they don’t think they need them.)
This sort of probationary supervision sometimes work for a while, as long as the client isn’t too ill, the meds are available, there is regular professional assistance (e.g. counseling and monitoring medications), the client has a regular source of income (either through family, state assistance, or they are lucky enough to find a job they can do and keep), and the probation officer knows what they are doing (i.e. they under stand the nature of the illness, they prioritize treatment of the illness, and they don’t try to hold the mentally ill individual to the same standards of behavior as “regular” clients). Usually some link in this chain breaks. At that point it is only a matter of time until the client violates the orders of their probation (often violently).
The Judge ends up with little choice but to send the individual to prison. Now we have a significant portion of our mentally ill population warehoused in our prisons. (see quote above) It is hare to argue that this warehousing (mixed in with true criminals) is in any way more humane that the state hospitals of the 50′s.
Where do we go from here? Well, get out your wallet, it is going to cost money no matter what we do. It really amounts to a “pay me now or pay me later” situation.
One possibility is to improve the delivery of services in the community. We could adequately fund the necessary programs. We would have to have a change in the Mental Health system mindset, however. The new mindset would have to be that violent mental health patients can’t be excluded from services, a realization that they won’t participate voluntarily and some level of coercion is necessary (the courts would be fine in that regard), and the system would have to get over the “it’s the client’s choice” mentality when dealing with these individuals specifically. When all is said and done, it may actually be easier to come up with the money than to change the mindset.
The second possibility is to improve probation. We could fund programs to train probation officers to correctly supervise violent mental health patients. We could fund the placement of mental heath professionals is the probation system to provide services within the framework of the probation system, who could operate in the “non-voluntary” world.
A third possibility is to expand the state hospitals. If we are going to warehouse violent mental health patients, it would seem better to do it in a state hospital. They would be more likely to get adequate treatment and would be less likely to be victimized by hard-core criminals.
The fourth possibility is to do nothing. If so, the number of violent mentally health patients in prison will continue to expand. We will end up paying later for more prisons. The only real advantage in doing it this way is that the cost is hidden, because the violent mentally ill felon just shows up as another criminal in the system. This gives “law and order” candidates something to rant about at election time, because on paper it looks like the crime rate is going up and we need more prison beds.
Of course, I have an opinion on the matter. I think ideally, the first option is the best. The mental health system is already there. Theoretically it is best equipped to deal with the problem. It’s just that I have absolutely no confidence in the mental health system’s ability to adjust their operational mindset (or at least not in the short amount of time necessary). Frankly, I don’t think it will happen.
I think the most viable option is to improve probation. Probations officers are used to dealing with a variety of social problems. With appropriate resources, they can probably handle it. The real weakness of this approach is that it doesn’t address the needs of the violent mentally ill individuals who are not yet in the system.
I don’t think expanding state hospitals is an option. It would require massive funding to expand their capacity. It would take a massive re-thinking of our rules for admission and length of stay criteria for the hospitals. The necessary changes are probably not viable under current civil liberties law.
My best guess is that we won’t do any of those and will end up building more prisons to take the problem off our streets and out of our sight. But, make no mistake. We will end up paying for it The violent mentally ill are going to be dealt with one way or another.