Magazine | July 10, 2017, Issue

Mental-Health Priorities

Insane Consequences: How the Mental Health Industry Fails the Mentally Ill, by DJ Jaffe (Prometheus, 363 pp., $25)

Donald Trump’s election suggests many things about Americans. Among them: Many of us are sick and tired of political correctness. Much of the country cringes when the president makes outrageous comments — but much of the country loves it. There is something deeply satisfying, to many people, about insulting people you’re not supposed to make fun of and questioning prevailing assumptions. The problem, of course, is that it’s often counterproductive to be offensive. Politically incorrect statements and tweets can preclude alliances and impede policymaking.

DJ Jaffe’s new book is an important reminder about the useful side of flame-throwing. Being politically incorrect can create change when it’s done with a strategic sense and a clear sense of policy direction. Insane Consequences is an unapologetic critique of the approaches and assumptions of the mental-health industry and mental-health advocates. By stating — boldly — that prevailing approaches to mental illness have “insane consequences” for those who most need assistance, Jaffe will infuriate many readers. But his attack has the potential to make a positive difference, in showing how to make alliances in challenging the status quo and how to change policy by debunking assumptions. This is an indispensable book for advocates for the seriously mentally ill and policymakers who want to change the system.

Jaffe’s driving critique is informed by a single problem: A small but significant part of the American population (Jaffe says 4 percent) suffers from severe mental illness (SMI). Around half of them, at any given time, are not receiving treatment. This treatment gap has awful consequences for the individuals afflicted, for their families, and for their communities. I see these consequences in my work with law enforcement. Every day, police encounter people with severe mental illness who are not getting medical attention — the man on his roof being tormented by demons, the mom whose son attacked her and the family cat, the concerned citizen hearing awful sounds next door when his neighbor screams at his visions. As Jaffe points out, tens of thousands of people with SMI are homeless, and many are drug-addicted. People commit bizarre and violent acts because of their afflictions. It is not politically correct to connect mental illness with vagrancy and crime, but this is the reality that we must confront.

Jaffe is not the first person to speak frankly about the suffering related to severe and untreated mental illness. He is, however, one of the few who analyze the causes in a clear and approachable way. That millions of Americans are not receiving treatment for their diseases is a complicated problem that has been many decades in the making. Among the police I work with, there is a sense of fatalism about the situation, a belief that the mental-health system is too entrenched, too intricate, and too dysfunctional to change. Jaffe ably cuts through this thicket.

There is a standard narrative about why untreated SMI exists: Many decades ago, people learned of the horrible things happening in state-run insane asylums. A process of deinstitutionalization was put in place whereby state facilities were scaled back or closed, and people with mental illness were sent back to their communities. According to this story, the problem is funding: People returned to their communities without adequate services in place, so they became neglected. If only the federal government would send more money to counties to provide mental-health services, people would get the care they need.

Jaffe’s description of the problem doesn’t deny that deinstitutionalization occurred or that financing problems exist. But these are not the fundamental problems. The reason so many people with SMI are untreated, according to Jaffe, is that mental-health providers and mental-health advocates choose not to help them. Assisting people with SMI is difficult and expensive, so the mental-health industry “cherry-picks the most compliant and least symptomatic.” In the case of the advocate community, admitting that untreated people with SMI need serious help is highly inconvenient. It conflicts with advocates’ brittle beliefs about individual rights, self-determination, and the immorality of involuntary treatment. Instead of helping the seriously mentally ill, mental-health advocates actively work against them, using public pressure and litigation to get them out of treatment.

One of the important takeaways here, for Jaffe, is that people with SMI suffer because of recent and ongoing decisions by authorities, not decisions made decades ago. People aren’t getting the care they need because of bad rules and ideology. There is plenty of money being sloshed around, but it’s being spent in the wrong way: “The problems are fixable, and solving them is affordable.”

Jaffe’s ideas for reform rest on three basic assumptions. First, there is a critical difference between mental illness and serious mental illness. The definition of SMI may be debated, but the central fact remains: There is a fundamental difference between diseases such as schizophrenia and major bipolar disorder and ailments such as stress, trauma, and low-level depression. Second, when SMI is untreated, a high degree of suffering ensues: There are serious and even tragic outcomes for afflicted individuals and people around them. Third, many people with SMI need involuntary treatment. Many of them lack awareness of their illness; brain disorders cause people to resist and resent treatment. The current practice, in many states, of setting the bar high for involuntary treatment is dangerous and inhumane. Programs should be favored, in outpatient and inpatient settings, that mandate medical treatment.

In the light of these three assumptions, it’s clear that programs promoting broad “mental health” solutions and feel-good anti-stigma campaigns should be cut; that funding should be targeted to evidence-based programs serving people with SMI; and that rules that discourage treatment — such as the Medicaid “IMD Exclusion” — should be immediately rescinded. (Jaffe’s four-page treatment of the perverse incentives created by Medicaid, Medicare, and Social Security Disability Insurance might be the best quick summary available.)

Jaffe advocates programs that serve the needs of the seriously mentally ill by giving them supervision, structure, and medical care: more psychiatric beds, intensive case management, teams of people providing care to help patients live safely in community settings. He is a strong advocate of court-supervised programs, such as mental-health courts and assisted outpatient treatment, because of their accountability mechanisms (for both participants and mental-health professionals). He urges advocates of these reforms to form alliances with police and corrections officers. These two groups, more than any other, understand the flaws of the current system.

Jaffe misses an opportunity to make the same critique of people in the criminal-justice system that he gives of people in mental health. In Jaffe’s telling, police and corrections officers are the victims of a failed mental-health system. They interact with the mentally ill because other people and systems fail, and it’s not fair that they should have to deal with the consequences. There is truth in this perspective, to be sure, but it misses something important: Interacting with people with mental disorders is a central part of policing and jailing, and will continue to be as long as we live in a society where civil rights are balanced against people’s need for treatment. Many people with mental illness disturb the peace or violate the law but do not reach even the lowest thresholds, in the most treatment-friendly states, for involuntary commitment.

Criminal-justice professionals must acknowledge this as an important part of their job and take responsibility for it. This will open up new approaches and treatments — such as having mental-health professionals do case-management work within police departments, or having jails provide meaningful therapy and treatment. Jaffe gives a pass to police and corrections because, I think, he wants to win them over as allies; this is perfectly understandable, but we should also raise expectations.

Jaffe has written a powerful book with a clear and important message. It’s both politically incorrect and true to say that the mental-health system fails the most mentally ill. Jaffe often overstates his critique of agencies and programs (many people in community-health organizations do great work, for example, as do disability-rights activists). But his unapologetic, in-your-face approach is powerful, and his cause is of the highest importance. He will, I hope, help bring more care to people desperately needing our help. It’s worth enraging some people.

– Kim Hendrickson is the program manager for the Behavioral Health Outreach Program in Poulsbo, Wash. She works with police and courts in Kitsap County to address mental-illness-related issues.

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