Monday, January 24, 2011

The Personal Freedom Dilemma and Mental Illness

Well here's a link to a good article by Sharon Begley that appeared in Newsweek a few weeks back that got me to thinking again about the difficulties suffered by families of the mentally ill and about the role of the criminal justice system in dealing with mental illness. The piece is about the difficulties that parents can have when trying to get treatment for mentally ill children, particularly, but not only, when their kids are unwilling to admit that they have a mental illness or are resistant to a hospital admission.
There's nothing particularly groundbreaking in this article, and to people who work in or around the mental health system, the anecdotes contained in the article aren't going to come as a surprise (my own experiences with the mental health docket made most of the situations found in the article all too familiar), but within our larger population (i.e., the larger population of people out there who haven't really had to deal with serious mental illness on a personal or professional level) I think that the breakdown with the mental health system remains a story that's much less widely known and understood.
As I've complained many times before on this blog, the mental health system in this country remains tragically underfunded and ineffective. We simply don't have nearly the number of required hospital beds, doctors, or treatment facilities necessary to deal with our mentally ill population. As Begley's article points out, hospitals and mental health facilities, chronically underfunded, find themselves in a position where they're restricted to treating only the most serious of cases, typically reserving hospital admissions for situations which pose an immediate, imminent threat of physical harm while placing all other patients on long waiting lists for outpatient services. (a situation which is all but untenable for parents and/or family who are living with a floridly psychotic, extremely paranoid, or hypermanic individual) Even in these sorts of situations, treatment is often limited to stabilization which relieves the immediate threat, but the long term follow up care may not do much to prevent such incidents from arising in the near or far future. Private insurance frequently provides minimal, if any, coverage for mental illness, with coverage falling far short of what is medically advised or required (short term stabilization is sometimes possible for people with private insurance, but longer term hospitalization and/or long term, ongoing psychiatric treatment is rarely covered).
In addition to the problems arising from a lack of resources are thornier issues regarding personal liberty and the reluctance of judges and public officials to proceed with involuntary commitment for individuals who are unwilling to acknowledge their illness or accept treatment. On the one hand, I understand the need for a preference toward personal liberty (the great majority of people with mental illness pose no risk to anyone, after all, and we don't need to create a system where we end up locking away every ill person who ever makes someone else feel uneasy or uncomfortable for a moment). On the other hand, as the system currently sits it appears that most judges aren't going to really think that a person is suitable for an involuntary commitment (the standard requiring that the person pose a risk to himself or others) up until the time that the person in question has actually caused some sort of harm to himself or to another person.
I work the mental health docket, and I struggle with this stuff all of the time. I only work on misdemeanors, so things usually haven't gotten too far out of hand when I get my cases, but I'm usually looking for some sort of signs that the defendants on my caseload aren't headed toward doing worse and more harmful things. When a guy is just sitting at a bus stop and yelling at people, he's going to be harmless 95% of the time. I have a high volume of cases where people do some things that seem alarming or even mildly menacing (things that might especially seem menacing to people in the general population who aren't used to dealing with mentally ill people), but these same defendants don't have any sort of criminal record that would ever reflect that they're capable of any real violence and most of them never will.
I can and do try to see about referring these people to services when I can, but typically, at best, they just get stabilized and/or put on some kind of waiting list for services. So, given the high volume of people that I see who engage in bizarre behavior on a regular basis, and knowing that the vast majority of them are harmless, what am I supposed to do? I could lock all of them up for as long as I can (which isn't very long, anyway, on a misdemeanor docket) in the hope that I'll maybe, possibly happen to catch the one guy who ends up going on a shooting spree at some point.
Given the fact that "warning signs" are always much clearer in hindsight, however and that I'm dealing with hundreds of these cases (at least) every year- most of which will never amount to anything more than a momentary irritation for the people involved- I find it hard to believe that handing out harsh punishments for symptomatic conduct is really the way to go. It just doesn't seem right. If our mental health system weren't so broken in the first place, most of these people would be hospitalized or in institutions and wouldn't be out on the street to get themselves into trouble in the first place.
But I 'm not going to lie. I still worry about getting a Jared Loughner on my docket- that one guy in a hundred or a thousand who is going to go on to shoot up a grocery store parking lot. When that sort of singular individual goes off the deep end and creates a bloodbath, and "they" later go back over his criminal records, I fear that there's going to be a lynch mob outside my office door, wondering why I didn't "do something" about this guy when I had him in court on a criminal trespass or for making some threatening comment to someone at the liquor store. I'm not sure it's going to appease "them" when I try to defend myself by saying that the mass murderer was one out of hundreds of cases just like him, indistinguishable from the harmless defendants in the rest of the pile.
But as things sit right here and right now, I'm here to tell you that I seriously think about these things all of the time, and there's not a heck of a lot that can be done- or if there is, I'm missing it, and I'm more than open to suggestions.


cardboardbelts said...

I'm not totally sure that Jared Loughner has a mental illness. I think we may have jumped on that wagon a little too quickly. This thought is largely unrelated to your post, but, I believe, is one worth considering.

J.S. said...

You might be right (especially given the fact that he was apparently prone to using hallucinogenic drugs), but given what I've read about the guy's behavior so far my guess is still some sort of mental illness (with my money being on schizophrenia or schizoaffective disorder with paranoia).
I know that people are quick to jump on the bandwagon with their guesses, though. I'll be curious to hear what the docs can come up with if they can get him to cooperate enough to do a proper diagnosis.