When I break down just a little and lose my head

11 01 2011

Deep breath.

I don’t know if this is the first but I do plan for it to be the last time I talk about this.

This is about Jared Loughner. And me. And the one thing that might connect us: neither of us were committed for mental illness.

As mentioned previously, I do not know if Loughner is mentally ill, and I really wish so-called experts would quit diagnosing him over the airwaves. But mentally ill or not, his actions prior to the shooting have led to a fair amount of discussion as to whether he should have or could have been committed.

Here’s where I come in: A half a lifetime ago, I had a commitment hearing. It was not a pleasant experience.

The judge was fine, the court-appointed attorney was fine, even the room in the locked ward of the psychiatric wing of the hospital was fine. And I wasn’t even committed, tho’ I do think I had to agree to stay on the ward and do x, y, and z.

I was deeply angered at having been incarcerated in the psych ward in the first place, and for years afterward felt that the incarceration was both unjustified and unjust.

Hey, I just wanted to kill myself, that’s all, no one else. No big deal.

The details are, pfft, details. There were cops and handcuffs and then at the hospital, restraints (which I managed to pull off*)—all of which sounds ghastly and it was, but it was ordinary, too.

Ordinary in that the cops were decent, as were the hospital staff, and the ward was clean and everyone had their own semi-private rooms and it was probably as good as these truly shitty things get.

It sucked, yes, and it sucked because I needed to be there.

It took me awhile—years—to realize that corralling me into a psych unit was both just and justified.

So, zoom back out: Does this mean I believe that everyone with an untreated or refractory mental illness should be consigned to a psych ward?

No.

But while it might have once been too easy to commit people for too long (for-ever. . .), the problem now is that too many people—both those who want help and those who don’t—have difficulty getting that help.

That’s where the focus should be: on access to good treatment for mental illness. Any discussion about making involuntary commitment end must begin with that concern.

William Galston goes about this the exact wrong way:

The story repeats itself, over and over. A single narrative connects the Unabomber, George Wallace shooter Arthur Bremmer, Reagan shooter John Hinckley, the Virginia Tech shooter—all mentally disturbed loners who needed to be committed and treated against their will. But the law would not permit it.

Starting in the 1970s, civil libertarians worked to eliminate involuntary commitment or, that failing, to raise the standards and burden of proof so high that few individuals would meet it. Important decisions by the Supreme Court and subordinate courts gave individuals new protections, including a constitutional right to refuse psychotropic medication. A few states have tried to push back in constitutionally acceptable ways, but efforts such as California’s Laura’s Law, designed to make it easier to force patients to take medication, have been stymied by civil rights concerns and lack of funding.

We need legal reform to shift the balance in favor of protecting the community, especially against those who are armed and deranged.

Yes, the point of treatment is not the unwell, it’s the rest of us.

Think I’m misreading Galston? Well after arguing for an expanded list of people who should be held legally responsible if they have “credible evidence” of someone’s “mental disturbance” and don’t report it to “both law enforcement and the courts”—not emergency rooms, not health officials—he argues that “A delusional loss of contact with reality” (whatever that is) should be enough to begin the process of commitment.

To be fair, he does say this process should include “multiple starts with multiple offers of voluntary assistance”, which, if one doesn’t volunteer, could end with “involuntary treatment, including commitment if necessary.”

That actually would sound reasonable as a way to try to get help for people, except, of course, that’s not Galston’s real concern:

How many more mass murders and assassinations do we need before we understand that the rights-based hyper-individualism of our laws governing mental illness is endangering the security of our community and the functioning of our democracy?

That’s right: people sleeping on heating grates or hiding out in rooms or basements and unable to care for themselves or anyone else is not the threat to democracy, it’s that “mentally disturbed loners” might take a shot at a president or pop star or member of Congress.

I have absolutely no truck with murder and assassination, and believe that if better care for the mentally ill would lead to fewer violent crimes, that would be wonderful.

We’re not going to get that better care, however, if all that matters is the fear of the well and the punishment of the unwell.

Right now, punishment is the driving approach to mental illness. According to a 2006 Human Rights Watch report,

More than half of all prison and state inmates now report mental health problems, including symptoms of major depression, mania and psychotic disorders, according to a just-released federal Bureau of Justice Statistics (BJS) report, Mental Health Problems of Prison and Jail Inmates.

In 1998, the BJS reported there were an estimated 283,000 prison and jail inmates who suffered from mental health problems. That number is now estimated to be 1.25 million. The rate of reported mental health disorders in the state prison population is five times greater (56.2 percent) than in the general adult population (11 percent).

Women prisoners have an even higher rate of mental health problems than men: almost three quarters (73 percent) of all women in state prison have mental health problems, compared to 55 percent of men.

Galston should be pleased: we’re already locking up a lotta crazy folk! Too bad that they’re not getting treated once they’re in jail.

Prison staff often punish mentally ill offenders for symptoms of their illness, such as being noisy, refusing orders, self mutilating or even attempting suicide. Mentally ill prisoners are thus more likely than others to end up housed in especially harsh conditions, including isolation, that can push them over the edge into acute psychosis.

Would involuntary commitment have helped these prisoners? Again, if one follows Galston, the deranged should be reported to “law enforcement officials and the courts”, not to anyone actually in a position to help them.

And where would all of these people go, if not to jail?

According to Human Rights Watch, the staggering rate or incarceration of the mentally ill is a consequence of under-funded, disorganized and fragmented community mental health services. Many people with mental illness, particularly those who are poor, homeless, or struggling with substance abuse – cannot get mental health treatment. If they commit a crime, even low-level nonviolent offenses, punitive sentencing laws mandate imprisonment.

The new BJS report reveals that state prisoners with mental health problems were twice as likely to have been homeless and twice as likely to have lived in a foster home, agency or institution while growing up as those without mental health problems. Prisoners with mental health problems were also significantly more likely to have reported being physically or sexually abused in the past, to have had family members who had substance abuse problems, and to have a family member who had been incarcerated in the past. An estimated 42 percent of state inmates had both a mental health problem and substance dependence or abuse.

(See also: here, here, and here, or just run a search on “mentally ill prisoners”.)

I don’t think this is working. It’s just possible, in fact, that if there were better patient-centered options—options which could include involuntary treatment—that fewer mentally ill people would end up in jail. Good for them, good for us.

We can’t just jump ahead to involuntary treatment and commitment, however, before building up the infrastructure for all treatment, voluntary and not. It wasn’t until 2008 that the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act was signed into law, and even with that law, treatment for mental illness may legally go uncovered.

So let’s make treatment possible. Let’s make sure the vulnerable have a place to go where they can actually get help before we call on cops and judges. Only after we make sure treatment is actually available does it make sense to talk about laws to draft the resistant into that treatment.

There’s nothing easy about any of this, not least because some mental illness are just damned hard to treat, but if commitment is to be both justified and just, then it makes sense that in our rights-based hyper-individualist society that we actually pay attention to the individual at the center of the debate.

*This is why you should always wear a watch: if anyone tries to tie your wrists together or to something (like, say, the rail of a hospital bed), you can use the extra space provided by the watch to wrench and wriggle your wrist free.

~~~

Coda: I got lucky—although it sure as hell didn’t feel like it at the time—because I got care.

A person shouldn’t need luck to get care.

h/t The Daily Dish

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