Thursday, October 18, 2012

Freedom is Tyranny...

...when you're mentally ill.

Hacker News linked to this very interesting article in the Washington Post by Paul Gionfriddo, talking about how his own son fell victim to the very reforms of the mental health system that he himself helped pass as a member of the Connecticut legislature:
If you were to encounter my son, Tim, a tall, gaunt man in ragged clothes, on a San Francisco street, you might step away from him. His clothes, his dark unshaven face and his wild curly hair stamp him as the stereotype of the chronically mentally ill street person.
Tim is homeless. But when he was a toddler, my colleagues in the Connecticut state legislature couldn’t get enough of cuddling him. Yet it’s the policies of my generation of policymakers that put that formerly adorable toddler — now a troubled 6-foot-5 adult — on the street. And unless something changes, the policies of today’s generation of policymakers will keep him there.
An interesting mea culpa, to be sure.

(A long post, so more after the jump)

What were those reforms?
The 1980s was the decade when many of the state’s large mental hospitals were emptied. After years of neglect, the hospitals’ programs and buildings were in decay. In my new legislative role, I jumped at the opportunity to move people out of “those places.” I initiated funding for community mental health and substance abuse treatment programs for adults, returned young people from institution-based “special school districts” to schools in their home towns and provided for care coordinators to help manage the transition of people back into the community.
Hmmm. Mentally ill people are taken from dilapidated mental hospitals and placed in community care.

I have my hunches for what might be the problem with that plan. What is Paul Gionfriddo's diagnosis?
But we legislators in Connecticut and many other states made a series of critical misjudgments.
First, we didn’t understand how poorly prepared the public schools were to educate children with serious mental illnesses.
Second, we didn’t adequately fund community agencies to meet new demands for community mental health services — ultimately forcing our county jails to fill the void.
And third, we didn’t realize how important it would be to create collaborations among educators, primary-care clinicians, mental-health professionals, social-services providers, even members of the criminal justice system, to give people with serious mental illnesses a reasonable chance of living successfully in the community.
During the 25 years since, I’ve experienced firsthand the devastating consequences of these mistakes.
The problem, in his opinion, is essentially a lack of money and support.

But is that really the problem? Has Paul Gionfriddo actually learned anything useful?

It seems his son had a rough time at at the schools he went to, getting suspended for fighting with other students and for drug use.
What followed were many years during which one public school after another knew it couldn’t educate my son but had nothing to offer, holding him back in one case and bumping him ahead in another.
This certainly sounds rotten, but it's not clear how schools should deal with students who take drugs and fight with other students. Lack of money is almost certainly part of the problem, but it's a difficult task with all the money in the world to deal with students like that. Are they best off being dealt with by teachers trained in algebra, or mental health professionals trained in patient control? If all the schools you go to can't handle the problem, it's possible that all the schools are short on funding. It's also possible that schools aren't the right venue to be solving this problem, because they're fundamentally unsuited to it.

But it's only when Tim becomes an adult that we see things really going off the rails:
When Tim turned 18, he had no high school diploma, no job prospects and a debilitating mental illness. Legally an adult, he also decided he wanted to live on his own. With a brand-new diagnosis of schizophrenia, Tim was eligible for a variety of support services, but he now told us he didn’t want them. He was tired of counseling and he didn’t like the side effects of the antipsychotic drugs prescribed for him. He also didn’t want a caseworker checking in on him.
He got his wish. None of the overextended caseworkers assigned to him had time to devote to an unwilling client such as Tim.
The last two sentences are highly revealing.

The first seems to indicate that Tim voluntarily chose a course of action that was going to be harmful to him, which is not unexpected given that he's mentally ill.

But the second wants to shift at least part of the blame to the caseworker being 'overworked', and lacking 'time' to devote to an 'unwilling client'.

I find this latter assumption strange. Let's assume that Tim had his own full-time case-worker, with nothing but time and interest in his case. What, precisely, is the case worker meant to do if Tim continues to express a desire to refuse drugs, refuse counselling, and not be checked up on?

The consequences of this aren't entirely hypothetical, either:
When Tim finally found a landlord willing to rent him a place on his own, the mental health agency’s housing personnel gave him a bad reference. That kept Tim living on the streets, and eventually he drifted into homelessness and incarceration. When he was in jail, with its regular routines and meals, Tim usually stabilized. But when he was released — because he went back to the streets instead of to a service provider — he destabilized right away, which in his case meant becoming highly agitated and paranoid, and hearing voices.
I find this kind of astonishing. The answer is screaming out in his own words: Tim needs an ordered environment where he isn't left to make all of his own decisions. We know this because even when he was put in jail, which is a really crappy ordered environment compared with a mental institution, he showed improvement. Out on the street, with sensitive caseworkers to help him, but free choice, he had serious problems.

How exactly does this square with the previous assertions? Apparently we are led to believe that jails don't suffer from the same lack of mental health resources that plagued the schools where he had problems. I mean, maybe. Or maybe jails just have a lot of people who will force you to do what they think is in your interest, and are physically well-equipped to compel you to comply.

So what exactly are the policy prescriptions that we need?
If I were a legislator today, I’d mandate — and provide funding to ensure — that every teacher receive training in recognizing symptoms of mental illnesses. I’d see that pediatricians are trained to make screening for mental health concerns a regular part of well-child exams. I’d require school administrators to incorporate recommendations from pediatricians and mental health professionals into students’ IEPs.
With infinite money, let's turn every primary school teacher into a qualified medical professional to diagnose mental illness at young ages, notwithstanding that medical professionals themselves have great difficulty agreeing what constitutes mental illness in young children.
I’d put much more money into community mental health services. I’d integrate how services are delivered by funding collaborative community mental health programs and have them run by mental health professionals. I’d include services for chronically homeless people under this collaborative umbrella.
More money. Got it.
At the same time, to clear our county jails of people with mental illnesses, I’d get rid of laws targeting homeless people, such as those against loitering or sitting on a sidewalk. And I’d make sure that there was supportive short-term and long-term community housing and treatment for everyone needing them. Both were promised almost 50 years ago in the federal Community Mental Health Centers Act of 1964 — promises that were broken when it was repealed in 1981 and replaced by a block grant to states.
I've never had to deal with the immense sadness of a loved one with mental illness, and I have enormous sympathy for Mr Gianfriddo's situation. I also well understand that his actions reflect the best of intentions, as well as his ardent desire to find a way for his son to live a normal life out in the community. So it is with no disrespect that I say:

You've got to be @#$%ing kidding me.

By your own admission, the jail was the place where your son seemed to do better! And that's the first thing you want to get rid of??? Okay, then what? So now he's permanently on the streets?

Don't get me wrong, I think that jail is definitely not the place that we should be housing our mentally ill. Not by a long shot.

But the one answer that never gets countenanced is the very one that Paul Gianfriddo shut down in the 1980s: hospitalisation, forced if need be, in mental health facilities. Direct your extra funding there! I have no doubt at all that such institutions are almost certainly going to be horribly underfunded, because roughly nobody cares about the mentally ill except the families of the mentally ill themselves.

There is a very difficult medical and philosophical question here that I don't want to seem like I'm just punting on. And that is how exactly you determine who should be hospitalised against their will if they haven't yet committed any serious crimes. I'm not pretending that this has any easy answers. This becomes especially true when you consider the possibility of incorrect diagnoses.

But there definitely seem to be a reasonable class of people like Tim who are currently very poorly served under the assumption that they should be left to decide all of their treatment choices on their own.

Money cannot solve that problem.

The problem is that free will is a tricky concept when mental illness is stopping you from making rational and coherent choices. I'm all for libertarian free choice, but you'll forgive me for thinking that fighting for the freedom of the mentally ill to die on the streets is somewhat of a Pyrrhic victory.

Mr Gionfriddo, there are two, and only two choices.

The first is that you find a way to force treatment and regular routine on Tim, with or without his consent, either through hospitalisation or some other means, under the assumption that it will be for his own good.

The second is that you let him do as he wants, and live with the consequences.

Both these choices are immensely sad. There is no escaping that fact. Sometimes there are only bad and worse choices.

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