BREAKING INTO THE MADHOUSE
I started law school very shortly after the Supreme Court ruled that a person cannot be committed to a mental hospital merely to get her out of the way of the public. To commit somebody for involuntary hospitalization, you have to prove that she is dangerous to himself or others. Once she's in there, you have to treat her, not just warehouse her. As a matter of fact, one of my professors brought the case in which that groundbreaking ruling was made.
At the time, it was pretty easy to get people committed for just being a bother to their friends and relatives. It was also pretty easy to get insurance companies to pay the costs of such hospitalization. When there was no private insurance, it was equally easy to get the state to take care of it.
On the other hand, at the time that the courts ruled that mental patients had to be treated, there really wasn't much treatment available for most people with mental illnesses. There was electroshock therapy, of course, and surgery, and there were a few tranquilizers. That was about it.
We are all familiar with the dismal chronicle of "courts make commitment more difficult--large state mental hospitals close down--patients thrown on community mental health resources--Reagan cuts funding for community mental health." At the same time, private health insurance became less and less willing to pay for mental health treatment or hospitalization beyond a very bare minimum. Treatments for mental illness were changing at the same time. It really was possible for some people to pop a pill and stop hearing voices. So private health insurance companies came to mandate pill-popping as the norm for mental health treatment.
Now we have a couple of sets of problems. One is that the legal system that deals with people with mental illness was devised when The Problem was the tendency to hospitalize people who didn't need it. Now The Problem is our inability to hospitalize people who do need it. It is next to impossible to force a mental hospital to accept a patient. There is an obscure clause in the Illinois Mental Health and Developmental Disabilities Act providing a procedure for a patient or her parent or guardian to appeal a discharge from a mental hospital. So far as I know, it has never been used.
A few years ago, a young man with a mental illness drove his car into the State of Illinois building in Chicago. Nobody was hurt, and some architecture buffs might consider the result an improvement. It was later revealed that the young man's father had been trying to get him hospitalized for at least three years, but that the hospitals kept releasing him after the minimal 72-hour evaluation. We never did find out if the car crash succeeded in getting him hospitalized long enough to tackle his problems. But I suspect the Chicago area is now full of parents and guardians with architectural hit lists of their own. Apparently that is what it takes these days.
The other set of problems results from, as usual, our belief that our technology works better than it actually does. In this instance, I'm talking about psychoactive medication. The fact is, psychopharmacology is still an art rather than a science. Some meds work on some people with some disorders. For some people, with some disorders, nothing works. Many of the meds that do "work" cause side effects that some patients consider worse than the disease. When the medical profession claims that a psychoactive med "works", they usually mean that it gets rid of the symptoms most disturbing to the patient's family or friends or caregivers.
Normally, we figure that if we feel bad, we should be able to take a pill and feel better. After all, it works for headaches. But increasingly, our pharmacopeia is full of things we take when we feel normal, or even absolutely terrific, and then they make us feel awful. This is especially true of patients with bipolar disorder. In the manic phase, they feel great, really great. Then they take the meds, and immediately feel either "blah" or totally miserable. This is not, we fondly believe, what medical science is supposed to be about.
But we still believe that forcing people with mental illness to take their meds will solve all the problems they present to the public, and at least the worst of the ones they suffer themselves. Sometimes we're right. Often, we're not. There are patients for whom we haven't yet found a medication that will "work", even within this limited definition. And other patients for whom the medication that "works" from the point of view of society is sheer misery for the patient herself.
So now we are trying to find ways to make people with mental illness take medications that may not alleviate their condition, or may make them feel worse in the process, because at least they won't bother us so much. The Supremes were pretty clear that minimizing public nuisance is not valid grounds for locking somebody up. Is it valid grounds for forcibly medicating people? Since we haven't really found a way to forcibly medicate people yet, the issue has not yet been litigated.
In the meantime, people with mental illness afflict our esthetic sensibilities of sight, sound, and smell, and commit occasional crimes, some of them violent. Proving that such a person is "dangerous to himself or others" usually requires predicting human behavior, which even mental health specialists aren't very good at. It requires depriving people of liberty on the basis of what we think they might do, rather than what they have done. In any other context, that would be unconstitutional. In 21st-century, it is merely a bad game of guesswork, in which the judgment of the police is clouded by a desire to get minor criminals off the street, and the judgment of the mental health professionals is clouded by the inability to get needed treatment paid for. As a result, the two largest mental health facilities in the country at the moment are the Cook County Jail and the LA County Jail, not necessarily in that order. The one thing everybody assumes the American public will pay for is jails.
Okay, I'm kvetching. I have clients with mental illness, and it's impossible to do the right thing for them. All I can do is fall back on the Canons of Ethics, which require me to do what my client wants unless he is actively and seriously threatening some third party. So I have no trouble figuring out what to do, I just don't know how to handle the results. Neither does anybody else who works with mental patients.
Many years ago, my mother volunteered at the local mental hospital as an interpreter. Like many such places at the time, the hospital staffed some of its less taxing jobs with its more stable inmates. One of them, on this particular day, was answering the phones at the front desk when Mom came in. The phones were ringing nonstop, and after several minutes of this, the inmate-receptionist looked up at her and sighed, "This is a madhouse." Which of course it was. Where is that receptionist now that we need her?
At the time, it was pretty easy to get people committed for just being a bother to their friends and relatives. It was also pretty easy to get insurance companies to pay the costs of such hospitalization. When there was no private insurance, it was equally easy to get the state to take care of it.
On the other hand, at the time that the courts ruled that mental patients had to be treated, there really wasn't much treatment available for most people with mental illnesses. There was electroshock therapy, of course, and surgery, and there were a few tranquilizers. That was about it.
We are all familiar with the dismal chronicle of "courts make commitment more difficult--large state mental hospitals close down--patients thrown on community mental health resources--Reagan cuts funding for community mental health." At the same time, private health insurance became less and less willing to pay for mental health treatment or hospitalization beyond a very bare minimum. Treatments for mental illness were changing at the same time. It really was possible for some people to pop a pill and stop hearing voices. So private health insurance companies came to mandate pill-popping as the norm for mental health treatment.
Now we have a couple of sets of problems. One is that the legal system that deals with people with mental illness was devised when The Problem was the tendency to hospitalize people who didn't need it. Now The Problem is our inability to hospitalize people who do need it. It is next to impossible to force a mental hospital to accept a patient. There is an obscure clause in the Illinois Mental Health and Developmental Disabilities Act providing a procedure for a patient or her parent or guardian to appeal a discharge from a mental hospital. So far as I know, it has never been used.
A few years ago, a young man with a mental illness drove his car into the State of Illinois building in Chicago. Nobody was hurt, and some architecture buffs might consider the result an improvement. It was later revealed that the young man's father had been trying to get him hospitalized for at least three years, but that the hospitals kept releasing him after the minimal 72-hour evaluation. We never did find out if the car crash succeeded in getting him hospitalized long enough to tackle his problems. But I suspect the Chicago area is now full of parents and guardians with architectural hit lists of their own. Apparently that is what it takes these days.
The other set of problems results from, as usual, our belief that our technology works better than it actually does. In this instance, I'm talking about psychoactive medication. The fact is, psychopharmacology is still an art rather than a science. Some meds work on some people with some disorders. For some people, with some disorders, nothing works. Many of the meds that do "work" cause side effects that some patients consider worse than the disease. When the medical profession claims that a psychoactive med "works", they usually mean that it gets rid of the symptoms most disturbing to the patient's family or friends or caregivers.
Normally, we figure that if we feel bad, we should be able to take a pill and feel better. After all, it works for headaches. But increasingly, our pharmacopeia is full of things we take when we feel normal, or even absolutely terrific, and then they make us feel awful. This is especially true of patients with bipolar disorder. In the manic phase, they feel great, really great. Then they take the meds, and immediately feel either "blah" or totally miserable. This is not, we fondly believe, what medical science is supposed to be about.
But we still believe that forcing people with mental illness to take their meds will solve all the problems they present to the public, and at least the worst of the ones they suffer themselves. Sometimes we're right. Often, we're not. There are patients for whom we haven't yet found a medication that will "work", even within this limited definition. And other patients for whom the medication that "works" from the point of view of society is sheer misery for the patient herself.
So now we are trying to find ways to make people with mental illness take medications that may not alleviate their condition, or may make them feel worse in the process, because at least they won't bother us so much. The Supremes were pretty clear that minimizing public nuisance is not valid grounds for locking somebody up. Is it valid grounds for forcibly medicating people? Since we haven't really found a way to forcibly medicate people yet, the issue has not yet been litigated.
In the meantime, people with mental illness afflict our esthetic sensibilities of sight, sound, and smell, and commit occasional crimes, some of them violent. Proving that such a person is "dangerous to himself or others" usually requires predicting human behavior, which even mental health specialists aren't very good at. It requires depriving people of liberty on the basis of what we think they might do, rather than what they have done. In any other context, that would be unconstitutional. In 21st-century, it is merely a bad game of guesswork, in which the judgment of the police is clouded by a desire to get minor criminals off the street, and the judgment of the mental health professionals is clouded by the inability to get needed treatment paid for. As a result, the two largest mental health facilities in the country at the moment are the Cook County Jail and the LA County Jail, not necessarily in that order. The one thing everybody assumes the American public will pay for is jails.
Okay, I'm kvetching. I have clients with mental illness, and it's impossible to do the right thing for them. All I can do is fall back on the Canons of Ethics, which require me to do what my client wants unless he is actively and seriously threatening some third party. So I have no trouble figuring out what to do, I just don't know how to handle the results. Neither does anybody else who works with mental patients.
Many years ago, my mother volunteered at the local mental hospital as an interpreter. Like many such places at the time, the hospital staffed some of its less taxing jobs with its more stable inmates. One of them, on this particular day, was answering the phones at the front desk when Mom came in. The phones were ringing nonstop, and after several minutes of this, the inmate-receptionist looked up at her and sighed, "This is a madhouse." Which of course it was. Where is that receptionist now that we need her?
posted by WiredSisters at 2:08 PM
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