People of a certain age remember well the revelations by the former Legal Aid lawyer, turned then-respected journalist, Geraldo Rivera, of Willowbrook State School. It was horrifying to see how children were being treated in institutions, and gave flight to a movement to end state abuse of the mentally ill and intellectually challenged. It was not only an affront to their humanity, but the state couldn’t be trusted to care for them humanely.
The institutions were closed. The inmates (as they weren’t patients) released. The buildings and land sold off. A few years later, people started to wonder where all the homeless people came from. It became commonplace for criminal defense lawyers to see serious issues with their clients, who clearly were suffering from some sort of deficit.*
We fixed the problem of terrible institutions by creating the problem of the mentally ill on the street or in the prisons. So the New York Times has come to the rescue.
When President Trump mused that the mass shooting at a high school in Parkland, Fla., in February might have been prevented if the United States had more mental institutions, he revived a not-quite-dormant debate: Should the country bring back asylums?
Psychiatric facilities are unlikely to prevent crimes similar to the Parkland shooting because people are typically not committed until after a serious incident. Still, a string of news articles, editorials and policy forums have noted that plenty of mental health experts agree with the president’s broader point.
It often takes a tragedy for issues to get on the radar, and the answers that come to mind rarely serve to fix whatever caused the tragedy, but that doesn’t mean the issues aren’t real and worthy of attention. But let’s not forget that this was on our radar once, when Jerry made us see what was happening, and the voices of brilliance answered the clarion call. How did that work out?
Neither side wants to return to the era of “insane asylums,” the warehouselike hospitals that closed en masse between the 1960s and 1980s. Nor does anyone disagree that the “system” that replaced them is a colossal failure. Nearly 10 times as many people suffering from serious mental illnesses are being kept in jails and prisons as are receiving treatment in psychiatric hospitals.
Yeah, it failed miserably. The cries were passionate and filled with emotion, but the idea was akin to handing every person with mental illness or an intellectual challenge a unicorn and telling them, “ride. Ride like the wind.” The Times offers a new and improved unicorn.
1. DEMAND SENSIBLE COMMITMENT STANDARDS
2. CREATE A CONTINUUM OF CARE
3. STAND UP FOR INSURANCE PARITY
The editorial fleshes out what it means, so it’s worth reading. But the upshot is to propose some vague tweaks (“sensible”? As opposed to what?) that rely on the same failed assumptions that gave us prisons filled with the mentally ill and the same nice folks in government that gave us asylums filled with neglected and abused patients. Then again, if you believe in the magic of government to cure societal ills, then surely they will be more humane this time.
But the most curious aspect of the solution is the assumption that people want to be helped.
In practice, though, the three laws have yet to create true equity. “In some situations, you still can’t get into a psychiatric facility unless you are suicidal or otherwise near death,” says Ellen Weber, vice president for health initiatives at the Legal Action Center, a nonprofit that is fighting parity violations in several states. “That’s an abhorrent double standard. We don’t do that for medical or surgical need.”
There is one distinction between mental illness and medical illness that needs recognition. A person with a med or surg need will usually seek treatment. People with real mental illness too often will not. They don’t realize they’re suffering from mental illness. That’s part of their illness. Sure, they need, and deserve, treatment, but handing them a new unicorn isn’t going to work any better this time than it did before.
It would be wonderful if no person with mental illness ever walked into a criminal defense lawyer’s office again. Prison is the worst place for them, as they receive no treatment and are most likely to be tortured by the system. But this isn’t going to change by giving them new unicorns to replace the ones they rode to the criminal courthouse. That’s just nuts.
*While lawyers are not qualified to diagnose mental illness, we have the opportunity to deal with people who suffer from it, from bipolar to PTSD, and are constrained to face their serious breaks from reality. It offends advocates of de-stigmatizing mental illness when we note that real mental illness isn’t the “trauma” of hearing a lecture by Christina Hoff Summers and needing some Play-Doh and a puppy.
There is real mental illness, and it is every bit as much an illness as cancer. But along with de-stigmatization comes those who use it to conflate their politics or feelings, even the ordinary occasional blues, with mental illness. Differentiating between the two is the next frontier for helping those with real mental illness so that it isn’t reduced to an excuse for the conveniently sad.
Discover more from Simple Justice
Subscribe to get the latest posts sent to your email.
SHG,
Regarding one particular type of mental illness, your post raises an issue about which I am passionate.
Schizophrenia, as you well know, is a horrible disease. The idea that schizophrenics should, as you so aptly put it, be provided a “unicorn” and told to “ride like the wind” is the prevailing attitude even now.
Having sat on a mental health commitment board as the law chairman and thus having seen many schizophrenics suffering deep delusions, having represented floridly schizophrenic clients enmeshed in the legal system, and having sentenced schizophrenics who, for the short time they were before me, were lucid enough to plead guilty because they were taking their Thorazine or some such drug, I say that it is past time that we consider resurrecting the old times.
It is beyond cruel to impute to schizophrenics a free will knowing full well that many will end up on the streets or in prisons hearing dinosaurs, seeing dinosaurs, smelling dinosaurs or all three. These mostly gentle, timid and frightened souls deserve better.
For many schizophrenics, the continuing care they need–the consistent and sometimes forced administration of psychotropic drugs–can only be found in locked-ward mental institutions. For those without money and extremely strong support systems, these institutions are the only vehicles capable of treating the disease and devising strategies to allow these patients to return to the free world. Importantly, if and when these horribly afflicted people return to the free world, we must understand that the heavy hand of the state must be ever-present, mostly to ensure medication compliance or the disease will flare again out of control.
If your readers want a heart-wrenching insight into this horror of schizophrenia as the protagonist interacts with the wide world, return to 1991. Watch Robin Williams in The Fisher King. I venture to say that the viewer won’t be the same after seeing Williams’ portrayal. More importantly, I hope the viewer will come to understand that “free will” and uncontrolled schizophrenia are the antithesis of each other.
All the best.
RGK
Judge, I see tons of people with mental issues. It’s a very rare week that I don’t have at least one client in the mental unit at the jail.
I’m lucky, though. I’ve been able to educate the prosecutors I deal with about these kinds of issues. More importantly, maybe, is that they trust me when I talk to them about these people. Depending on the circumstances, they will agree to a much more lenient outcome that they normally would. If it’s a competency issue, when I tell them so-and-so isn’t living on the same planet we are, they will almost always dismiss the case and close their file.
The one thing I can’t do is get them into treatment. If they don’t want to get help, then I know I will see them again at some point. And I do.
REvers,
Good for you. Your powers of persuasion regarding prosecutors must be powerful. However, it must be depressing when the crazy guy leaves the jail. He probably has no place to go, and there is no hope that he will obtain or take the needed medications. As you say, you will soon see him again.
In short, I have enormous respect for your willingness to continue to work in corrections while dealing with these problems–I would rather put a gun in my mouth (which reminds me to take my meds) if I were you.
All the best.
RGK
Well, judge, it’s just a part of being a public defender in a court that has no statutory authority to deal with mental issues. Lacking a procedural method to deal with them, I had to come up with what I could. It’s better than nothing.
REvers,
Sorry for mistaking you as working in corrections. As a public defender or private CDL, one sees up close the problem with the severely mentally ill. What is worse you have a fiduciary duty to see to the welfare of your client until suddenly you don’t. As SHG suggest, once you take care of their legal problems, your obligation ends, perhaps with a referral to a mental healh provider and perhaps not. It must be an awfully empty feeling knowing that many times the wash and rinse cycle will just start anew.
My apologies again. All the best.
RGK
Over the years, I’ve been able to send a good number of clients for diagnosis and treatment. I’ve put together a group of psych referrals who are the real deal, not bullshit hacks. Do they follow up after they’re no longer under my “guidance”? Some do, some don’t, some I have no clue. The ones who break my heart are the teens/20s whose parents are in denial. I think of the life they could have had with treatment and the miserable life they suffered because their parents didn’t want to have crazy kid. What a waste.
I am one of those kids. From circa age 8 on, I was increasingly viewed and treated as a problem child. Somehow I managed to cobble together a life, rather than ending up dead or locked up.
As such, I applaud you for your efforts. That’s what the system ought to be doing, not that I believe that it could or would. That said, I am disturbed by the casual way that involuntary commitment is being discussed.
I’ve been in those facilities. I’ve also been in jails. I know which one I swore I would opt for death, if I had no other way out. the last time was last time, in my book. Send me to jail, judge. It’s better there.
P.S. I had a comment that seems to have been eaten. If it shows up, I trust you will use your usual good judgement regarding what to do with it. I put a few hours work into it, but if it’s gone, at least I had the practice in cutting and correcting things – and it probably wasn’t all that good. Besides, in the long run, the practice is more important than the comment.
Not sure where your concern about the “casual way that involuntary commitment is being discussed” comes from, as I don’t think anyone takes it casually at all. As to your earlier post, I was out for dinner, so didn’t get to moderate comments until now. Sorry about that.
No sweat, boss. Things happen, it’s just that usually I get a “pending moderation” tag and see the post itself. Didn’t happen, so might’ve been on my end, instead.
By “casual”, I meant that little to no discussion went towards where the people would be going, once they were out of the legal system. Thus my references to “black boxes”. My second comment’s reference to how you make sure that when you can, you send folks to care providers you trust, rather than tell them “go find medical care” was also supposed to call to that item.
Thank you for your understanding, sir.
N
It’s impossible to cover the million variations on a theme so that someone doesn’t feel that their particular situation wasn’t given short shrift. It’s hard when it’s something close to your heart. I get it, but don’t mistake it for being casual. Each person should get what each person needs, and it’s always unique to their needs, even if it doesn’t appear that way in my shorthand comments.
Rich–as you know and is pretty obvious, I don’t do criminal, but I wander into criminal courts a dozen-or-so times a year on just these issues. Primarily getting CDLs and the state to hustle the exam or to enlighten them as to what can be done with the seriously mentally ill in jails.*
Even after many years of doing this, I’m astounded that neither side agrees with me. I expect blow-back from one, but it’s often both that tell me to mind my business. I often see orders giving the evaluators 90 days to do the eval and another sixty to write a report. By the time it goes to hearing, easily nine months have passed, and I only get involved if someone is obviously incompetent as determined by a jail psychiatrist. For my money, them’s the people that know best because they see far more serious mental illness than any community-based psych, and that’s because we dump the seriously mentally ill in jails.
Why wouldn’t a CDL, regardless how they’re paid, want their client to get a timely eval where those that know this stuff best go out of their way to say the client is incompetent? This dog-with-a-bone business can get pretty stupid for observers.
I’m gonna break a rule by telling a story. I have a long history with a local fella with schizophrenia. He’s harmless–he doesn’t have underlying bipolar or psychotic disorders. Those are easy to spot because they’re often holding a bloody knife. He sued my clients, judges and even me a few times. A couple times a year, he’d show up in my office, just to see how I was doing. He’d say he was worried about me because I work too much and should take time off. I’d check on whether he was getting his meds, knowing he wasn’t because they made him feel numb. The last time I saw him, a couple years ago, he told me he couldn’t get meds because his bike was stolen, so he couldn’t get to the Salvation Army. He didn’t get his meds there, but you sometimes have to put the pieces together yourself.
When he left, I told my secretary to find him a bike.** Other stuff got in the way, and that didn’t happen so fast, but the bike sat in my office for his next visit. A couple months later, I got a letter from him, which began something like this: “Dear Mr. Skink, I guess you heard by now that I’m back home in DOC.” He’s doing 20 for stealing copper, which is his profession. That, my judge pal, is a stupid result from a stupid process, and it happens all the time.
It isn’t just treatment that’s the problem. Jails and prisons provide treatment in the same manner as state hospitals: talk and drugs. Both environments have their problems. But to grind them through the criminal justice system is just abhorrent.
*Prisons are very different. Most states have designated mental health facilities, so the inmates have less interaction with mental health prisoners. My interaction with the process is also lessened because sentencing is done. But I’d bet I’ve had more mental health-related cases than just about any other lawyer.
**SHG, who knew? I have something resembling a heart left!
I had an echo cardiogram a few years back. I told the nurse to print me a pic of my heart just to prove I had one. When I got back, I taped it to my office door.
My son came by a few days later and saw it. He said, “that’s the ugliest baby I’ve ever seen.”
As anyone who has dealt with a severely mentally ill person knows, and as you note, “the problem” is rarely that they cannot access any care anywhere; it’s that they actively refuse it because they don’t recognize their mental illness as an illness. And they can refuse various modalities at various stages, e.g., an involuntary commitment order does not necessarily authorize the hospital to compel treatment with antipsychotic medication. The New Reformers’ solution is to “demand sensible commitment standards” and “create a continuum of care,” but what about noting that diagnoses of severe mental illness such as schizophrenia aren’t nearly as clear-cut as they make them out to be. They’re diagnosed based on not-too-scientific observations of often-shifting cluster of symptoms. Then there’s the medication, which may only bring the patient back to a groggy semi-reality, but present such severe side effects that many reasonable people would refuse it if weighing the costs and benefits and presented with such a choice (particularly since failing to follow the medication regimen precisely can make the symptoms even worse).
It’s hard for me to say whether people with mental illness have access to care. One of the recommendations is insurance parity, but that’s a load of crap. How many homeless people have insurance? How many working people can afford the $14,700 deductible and copay for Obamacare? It’s one of those “solutions” only a NY Times editor could love. And we have no viable emergency care for mental health anyway. Call the cops? What could possibly go wrong? Except a bullet in the head.
It takes a really evil person to suggest all those mentally ill people with feaux gluten allergies be put in a room with the wheat-based play-doh….. and don’t even start with the multiple puppy disorder.
If anybody understands the horrors of multiple puppy disorder, it’s you.
A substantial factor in this is the lack of sense on the part of many mentally ill persons. Shysters can get their unicorns away from them for a few magic beans, and they are right back where they started. No unicorn, no functionality, not even a free ABA membership.
That’s why the trend is towards outpatient commitment, i.e. court ordered forced drugging in the community. It’s marketed as less intrusive to liberty than inpatient commitment but it’s really a cost saving measure. Come in and take your depot injection once a week or we come for you.
You have a valid point that the mad, bad and sad will always end up in prison or asylum so pick one for each. But you’re kidding yourself if you think schizos don’t like taking meds purely at out denial. I suggest you try their dog food first, i.e. high dosages over long periods of anti-psychotics. They’re no fun.
Hoo, boy, between the post and the comments, I’ve had more than one of my rant buttons pushed. With that in mind, I will do my best to refrain. I’m not real good at that, but here goes.
1. Unless there are psych credentials that I’m unaware of, as soon as the discussion leaves the legal system, everyone here is a lay person. Since my issues stretch back over four decades, and the attempts to treat go back over three, I believe that I’m as well-qualified as anyone here to discuss the medical side of this, and better qualified than most. I have real skin in this game*.
1a. A wise judge once said that those who send people to prison ought to spend some time getting to know what it’s like, where they are sending them. I submit that the same applies to involuntary, long-term mental illness facilities.
2. Some wise lawyers have occasionally opined here about how extreme cases make for bad law. This entire discussion is premised upon treating extreme cases as routine, based on the assumption that since they are all extreme, they must all be similar enough for a general solution to be applied.
2a. What happens when some well-meaning fool tries to craft a law that deals with a range of extreme cases that are only broadly related? Can you craft a law that handles serial killers, repeat killers, and those who have killed because of extreme psych issues in the same fashion, and do it well? Yet that seems to be the kind of solution being discussed here.
3. One of the mantras here is that when you want to make things better, you should take care that you don’t make things worse.
4. I have been held in both mental health facilities and jails. One of those places is so bad that, if held against my will in one of them, taking my own life is preferable to being held there. Guess which one that is. I’ll give you a hint: One is a horrible place to be in. The other is a sterile white hell.
5. The gist of the discussion is that the legal system handles cases involving the mentally ill poorly, on its best day. I agree. Move the patients out, and into medical care. But first, be sure that current medical care is up to the task.
Generalities are easy to discuss. Try thinking about the solutions that are being discussed in terms of the individual when imposing your solution upon someone who is covered by it. Will you be able to accurately describe what is going to happen to them, once passed off, or did you just do a quick tour of a nice facility, via an appointment with them?
Those clean, orderly facilities that look so good when you visit. Have you ever paused to consider how and why they are like that, when filled with people who have difficulty with staying orderly and interacting with their peers in the normal world. How do they manage to do that? The answers to that aren’t pretty.
Napoleon XIV got it wrong, unless it’s a center for those with very wealthy relatives. The rabble don’t go to those.
With apologies for the length,
Nemo
*That kid in Overland Park KS? That could have been me, and still might. I’ve abandoned FB, in part because of that. The topic under discussion involves me in a very direct fashion.
The post takes no position about what should be, other than that the Times’ “solution” is no solution. I suspect you may have read more into the affirmative message than was there, and the point, like yours, is that there is no easy one-size-fits-all fix for people who suffer from mental illness.
Thought the part about it being the whole, post plus comments, thing I was talking about had survived me slashing away hunks of irrelevancies. Guess not. The time I took working on it was another factor, since the lay of the land in the comment field changed, while I was away.
Anyway, between the gaffes that are visible and those that aren’t, I have a lot of review work to do. Maybe that will keep me out of your hair for a while. 😉
N
I have a soft spot for comments somebody worked really hard to put together. I appreciate effort.