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They do not all murder, of course, but the consequences are dire nonetheless. Severe and persistent mental illness is a factor in 10-15 percent of violent crimes, according to a 2000 Lewin Group report. This rate is much higher than the two percent of people with a psychotic condition (schizophrenia or manic-depressive illness) in the population and the incidents occur most often because they are untreated. They swell the ranks of the homeless and incarcerated as well. Taxpayer costs aside, the human toll is staggering. The commission, however, ignored this hard-to-treat group. Instead it focused on "consumers" — the politically correct word for psychiatric patients — who are willing and able to make use of treatments, programs, and opportunities. The commission even prided itself on soliciting testimony revealing that "nearly every consumer…expressed the need to fully participate in his or her plan for recovery." But they did not hear from the sickest silent minority that is languishing in back bedrooms, jail cells, and homeless shelters. They are too paranoid, oblivious, or lost in madness to attend hearings, never mind testify. Dubbing its vision the "recovery model," the commission believes that sufficient therapy, housing options, and employment programs will enable people with schizophrenia or manic-depressive illness to take charge of their lives. Many will, it's true. But thousands won't. Over half of all untreated people with a psychotic illness do not acknowledge there is anything wrong with them. These people aren't avoiding treatment because services are unattractive (though many are indeed dismal) or because of "stigma," as the report repeatedly claims, but because they don't even know they need care in the first place. The problem with
the recovery vision is that it is a dangerously partial vision. It sets
up unrealistic expectations for those who will never fully "recover,"
no matter how hard they try, because their illness is so severe. What's
more, exclusive emphasis on recovery as a goal steers policymakers away
from making changes vital to the needs of the most severely disabled. It is a policy with
devastating consequences, especially considering the condition of state
budgets. Just last month, the IMD exclusion forced the closure of several
beds for mentally ill felons in Miami who may now be forced to live under
far less-supervised conditions. Doubtless the timid
commission was afraid of censure from mental-health groups who reflexively
charge civil-liberties violations at the slightest hint of coercion. But
in fact, anti-psychotic medication, even when taken by a resistant patient,
restores personal liberty, freeing him to make his own decisions again.
Studies consistently show that the majority of patients initially treated
without their consent agree with the decision when asked about it in retrospect.
Newer mental-health courts, another coercive option, use judicial persuasion
and the threat of jail to keep minor offenders with psychosis in treatment
and on medications at least long enough for them to make informed decisions
about treatment. Despite our dismay, the commission got many things right. Among them it urged integration of funding agencies, medical, and social services. It promoted evidence-based treatments and programs and condemned the awful double bind in which many are forced to remain on meager disability income because taking on paid work would mean losing Medicaid coverage. These recommendations, while solid, are not enough to help a deeply troubled system recover. Ever since deinstitionalization began closing doors to state hospitals in the late 1950s, we have abandoned the sickest of the mentally ill to the streets and jails. Four decades later, the commission opted for the safe route and abandoned them as well. — Sally Satel, M.D. is at the American Enterprise Institute. Mary Zdanowicz is a lawyer and executive director of the Treatment Advocacy Center in Arlington, Va. |
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