Last week, the president’s New Freedom Commission on Mental Health released its much-awaited report, “Achieving The Promise: Transforming Mental Health Care in America.” President Bush had charged the 22-member group with making a “comprehensive study” that would “advise [him] on methods of improving the system.”
Unfortunately, the report is woefully incomplete. The commission did not take on the most difficult cases.
Andrew Goldstein was a hard case. In 1999 the 29-year-old New Yorker killed Kendra Webdale by pushing her in front of a subway train. Goldstein suffered from schizophrenia and according to his court-appointed attorney had stopped taking his antipsychotic medication. Every year thousands of people with psychotic illnesses stop taking their medications; often because they do not even think they are ill.
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.
One long-overdue change is helping those who need intensive long-term institutional care. Not only does the report fail to recognize the paucity of psychiatric hospital beds, it ignores a blatantly discriminatory aspect of federal law. The Medicaid Institutions for Mental Disease (IMD) exclusion law prevents states from receiving federal reimbursement for facilities with more than 16 beds, simply because its residents are treated for psychiatric disorders.
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.
The commission also neglected to advise the president on how to manage severely mentally ill people who stop taking their medications. There was no mention, for example, of proven strategies, such as assisted outpatient treatment (civil court-ordered community treatment), which is often necessary for those who have a reliable pattern of spirally into self-destruction or dangerousness when off medication. The commission’s hesitancy to address this treatment mechanism is especially odd given the results from instituting such measures. For instance, in New York, of those placed in six months of assisted outpatient treatment, 77 percent fewer were hospitalized, 85 percent fewer experienced homelessness, 83 percent fewer were arrested, and 85 percent fewer were incarcerated.
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.
Last, we come to the matter of stigma. The commission thinks that irrational fear and disapproval of the mentally ill explain public indifference to their welfare. While many are indeed fearful their attitudes are not inexplicable — they come from reading lurid headlines or dodging menacing or hallucinating individuals on the street. “The perception of people with psychosis as being dangerous is stronger today than in the past,” according to the 1999 U. S. Surgeon General’s Report on Mental Health. Unfortunately, the logical conclusion eluded the commission — stigma will continue unabated until we stem threatening and erratic behavior.
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.