STUDY THE PAST FOR INSIGHT INTO THE FUTURE
E. Fuller Torrey wrote the book “American Psychosis, How the Federal Government Destroyed the Mental Illness Treatment System”. This book documents how the fundamental misconceptualization of SMI during and after the strange mental hygiene movement led to the disastrous broken system that federal and state governments are still in the process of breaking even in the present. Doctor Torrey’s book and DJ Jaffe’s book “Insane Consequences” should be required reading for every legislator in the country. DueJusticeProject has a point of contention with a couple of passages in both books where experimental policy prescriptions are discussed, however, both books provide an excellent analysis of what has gone wrong and why. Advocates need to be knowledgeable about the ethos of the mental hygiene movement and how the belief systems of that era are still informing social policies to this day. Adherents to these beliefs are influencing legislators and thwarting attempts to reform laws and policies.
COMPETENCY RESTORATION AND OTHER MECHANICS OF “DUE PROCESS”
Many if not most states in the U.S. have been sued by the ACLU and Disability Rights organizations for holding people in jail detention for many months, sometimes in excess of a year awaiting competency restoration. The leadership of the organizations launching these lawsuits seem to have little appreciation for the cruel paradox of their lawsuits. Society would not tolerate a system that would hold a jail detainee captive from treatment for any other acute medical condition. Yet, people who are in medical crisis with psychosis (neurologically detached from reality and gravely disordered cognitively) are held like animals in jails, deprived of medical treatment. The truth is that they are not being held for treatment – they are being held so that prosecutors can have them prepared for prosecution. The consequences of these abuses are further damage to the brain, suicide, and potentially the need for higher doses of dangerous antipsychotic medications.
Supreme Court cases, such as Sell v United States need to be studied by advocates to detect where misunderstanding of serious mental illness forms the substrate for these defective and troubling rulings. Advocates need to network to discuss the mechanics of criminalization. M’Naghten’s Rule and Competency Restoration are symptomatic of a pathological system that is convicting and punishing people unjustly. Advocates must stand up against these injustices.
REFORM OF STATE MENTAL HEALTH PROCEDURES – The Dangerousness Standard
States that require that people become dangerous need to change their laws to a need for care standard. As things stand, the anti-stigma proselytizers in the advocacy and mental health industry have succeeded in influencing society to believe that the mentally ill are not dangerous. Juxtapose this with the dangerous standard for involuntary evaluation and treatment!
The fact is that someone who is behaving bizarrely to the extent that others feel unsafe, or showing signs of psychosis – meaning, becoming neurologically detached from reality, particularly if the person is anosognosic, is at high risk for something destructive happening. Destructive means committing a crime or harming themselves or others. The dangerousness standard requires that the individual deteriorate to an acute medical condition for which there may be no explicit manifestation of dangerousness before someone can even enter into a battle with the system to get the person admitted for evaluation and treatment. (Pennsylvania state codes require moreover, that there be an act in “furtherance of a threat” – an outrageous and patently ridiculous standard that almost asks as a solicitation for someone to be harmed). The state refuses to step in proactively to compel involuntary evaluation and treatment on the basis of its duty to protect, yet will forcibly medicate someone to make them “competent to stand trial” after someone has been victimized or killed under the Sell v United States justification of the duty to protect society – by putting the person on trial.
People with serious mental illness (SMI) are generally no more likely to be violent than anyone else. However, based on biological factors, certain symptom profiles, a small percentage of people with untreated SMI are much more likely to be assaultive, engage in predatory-type behaviors that precipitate violence, or act out in paroxysmal episodes of violence. The general public, juries, and judges, generally do not understand how SMI works to cause assaultiveness or unlawful behaviors – they do not understand the consciousness disorder aspect of psychosis, command hallucinations, disinhibitions, clinical delusions, and acute dysphorias.
In the future, neuroscientists will come to understand a great deal more about electrical and chemical abnormalities in the brain that can directly cause goal-directed and paroxymal-type violence in human beings. Advocates for people with SMI who commit acts of violent are not indifferent to crime, insensitive to the devastating harms done to victims, or insufficiently outraged about violent crime. These advocates have rare insights into SMI that the greater part of the populace does not have. SMI is relatively rare and very difficult to understand. Very few people have direct exposure to SMI, particularly in a close family member. These advocates know that many thousands of people are being unjustly prosecuted, convicted, and punished.
One day neuroscience will discover things about the human brain and semblance of mind that will cause humankind to realize that in times past, people were being punished for behaviors that were beyond their neural capacity to control. It is painful and distressing for people who do understand SMI to stand by and watch this injustice happen. One day researchers will be able to reveal their discoveries to lay persons using language that we can all understand. Until then, the work of advocates will continue to be extremely challenging. We know that even then, the “Freudians” will still cling to outmoded theories. They will continue to conduct contra-research studies to “prove” stress/trauma/abuse/epigenetics hypotheses of SMI. They will not outrun neuroscience over the long haul.
Prominent foundations and federal government must step up funding of research and dynamic diagnostic tools in order to get to the bottom of the psychosis violence connection.
There is another potential benefit of increased attention being paid by the research community to study of the brain: It just may be the case that the brain is not just the seat of consciousness and semblance of mind, of command and control over human behavior. Scientist may just find out that the brain has control over all bodily functions in ways that are not currently known or understood. Unlocking the brain’s secrets may lead to cures for – or insights into other afflictions of the human body.
Talking About Mental Illness in the Media Spreads Ignorance Far and Wide.
Misunderstanding of serious mental illness is the root cause of the broken mental illness treatment system, dysfunctional and destructive public policies, and criminalization of SMI. Among the most serious problems is segregation of medical services for neuropsychiatric disorders into a so-called “mental health system”.
The medical profession needs to reconfigure itself to reconcile with the modern scientific understanding of psychosis -spectrum disorders. Federal and state governments, and modern medicine should leave the “mental health system” to psychologists and psychoanalysts and fully integrate the medical management of neuropsychiatric disorders into the “physical” healthcare system. Many doctors in other medical specialties other than psychiatry do not understand much about SMI – that needs to change.
Parents need to be educated on how to identify the signs and symptoms of emerging psychosis-spectrum disorders. Researchers are making slow progress toward identifying biomarkers for risk of later development of psychosis. For now, most competent doctors believe that early diagnosis and treatment may forestall the development of the most serious stages of psychosis. Researchers need to develop more effective, less dangerous medications. At present, researchers still do not fully understand why present day pharmaceuticals work to quell psychosis. As researchers understand more about the brain and SMI, other non-pharmaceutical interventions and adjunct treatments might be identified. The populace needs to be educated in order for advances in early treatment to save lives from the devastating consequences of having SMI.
The population needs to be re-educated to dispel folk psychology-based notions of SMI. We must stop talking about SMI using the same expressions that are used in public service messaging about “mental healthWe must cease being afraid and uncomfortable talking about the realities of psychosis in the subset of people that advocates are calling “The 4 percent”. People need to recognize signs of psychosis in their partners and in their families before tragedy strikes. If the general public is told to look for “depression”, sadness, loss of interest , social withdrawal, etc. then psychosis is probably not going to be caught early. In the U.S., the Surgeon General of the United States, perhaps working in conjunction with the NIMH, may have an important role to play in re-education.
There has been a epidemic of high-profile media stories about school shooter who were said to be “depressed”. In many cases, the parents did not comprehend their child’s illness. Who on earth would expect someone to shoot up a school because they are despondent or “depressed”. The colloquial use of “depression” is a thousand miles apart from the neurological realities or experience of the clinical “depression”. Parents also need to understand that distinctly classified disorders such as Bipolar, Schizophrenia, and Clinical ‘Depression'” are not so distinct as researchers have long suspected (and are substantiating via research studies). The general public needs to be educated to understand this! No one perpetrates a mass shooting because of some of the ordinary psychological or emotional struggles that are speculated about by the media and common folks.
EXAMINE THE MISINTERPRETATION OF THE OLMSTEAD RULING
There is an intersection between Olmstead and Criminal Justice. Lack of proper supported housing for the case management of SMI catapults vulnerable people into a criminal justice system that does not understand psychosis – but that is only one aspect of the intersection. Judges are convicting and sentencing people to prison making explicit statements to the effect that they know that diminished criminal liability sentencing or insanity dispositions will result in people being stepped down from high-security hospitals to unsafe community placements where the subject will go off his or her meds and become a danger to society. Ultimately, if judges are sending philosophically innocent people to prison for fear of the application of a Supreme Court ruling, then something is horribly wrong. This abuse of the most vulnerable citizens under the law must stop.
VOR, a disability rights organization (which is not an org that is mental-illness oriented) has an excellent position statement paper on the topic of Olmstead. VOR asserts that state and federal governments have intentionally misapplied the Supreme Court’s ruling. The impact of this willful misinterpretation has been devastating on the lives of people with SMI.
SMI is a particular type of disability that is different from all others for which special protections are needed under the law. Disability and civil liberties advocates have unintentionally harmed people with SMI via their activism. The ADA has failed to protect people with SMI based on their unique characteristics of disability, enforcing one-size-fits-all policies that have led to homelessness and engagement with the criminal justice system. The criminal justice system is exclusively responsible for mass incarceration, but misguided public policies and enforcement policies of the Justice Department against state institutions of custodial care and treatment have channeled the most seriously mentally ill into the cauldrons of criminal justice. SMI advocates need to push back against policies that are ill suited to the needs of people with serious brain disorders.
Some states even have an ‘Olmstead Plan’. Most of them should be scrapped.
DEFINITIONS OF INSANITY
The Supreme Court permitted the states to define insanity for themselves. Under the law, “Insanity” does not equate to serious mental illness. This disconnect provides the substrate for a host of abuses and injustices. Serious mental illness must have its own explicitly defined carve-out under the law. M’Naghten’s Rule is the most offensive and unjust of all legal definitions of insanity, especially in its abridged forms – but few people can understand why because they do not understand SMI. Advocates for people with SMI must confront M’Naghten’s Rule head on and challenge lawmakers on the basis of the realities of serious mental illness. Advocates must not fear ostracization and antagonism.
AOT, MENTAL HEALTH COURTS and INTERCEPT MODELS
Mental health courts propose to be compassionate and merciful toward people suffering from SMI, yet their program language speaks of “recidivism” and reversion to jail time if treatment plans are not adhered to. An institution of the law that speaks of symptomatic behaviors as “recidivism” and which punishes the consequences of anosognosia with jail time is not compassionate. A mental health court that conducts its affairs in this manner demonstrates that its operators do not understand serious mental illness. Diversion programs need to be overhauled to reconcile with the medical science of SMI. Someone with SMI who has been assessed to be unsafe, unwell, and possibly a danger to others should be placed in a medical facility or crisis stabilization facility when they refuse treatment, not a jail.
STATE GOVERNMENTS MUST PUT FUNDING FOR SMI AT THE CENTER, NOT THE PERIPHERY OF BUDGETS.
There should be zero-tolerance for letting people with SMI fall through the safety net into homelessness and incarceration. The precursor to Incarceration is harm to society. The law is perpetrating some egregious abuses upon people with SMI via the criminal justice system under the banner of protecting society. State and federal government is only demonstrating that its real goals are to shuttle people with SMI off to the underworld of society, i.e. jails and prisons, when funding for supported housing, state hospitals, and community treatment resources are perpetually vulnerable to budget cuts.
We don’t stash people with Alzheimer’s Disease in independent living units to fend for themselves with case workers to check in on them. We don’t let people with dementia roam the streets as homeless people when it is known that they are afflicted with a neurocognitive disease. Why are state and county governments satisfied to place people who become neurologically detached from reality in housing situations that are inappropriate or allow them to lie in the streets uncared for? The reason why people with SMI are abandoned to homelessness and improper housing is that their brain disorders are misunderstood.
STIPULATE THE CONSEQUENCES OF UNTREATED PSYCHOSIS
We need to recognize what psychosis can produce disordered thinking that can lead to dangerousness. Psychosis can happen to anyone with the biological risk factors that cause it. Society should not be shocked when the mother with post-partum psychosis kills her child. Society should not be shocked when someone kills a parent, family member, or someone outside the family when the person was in the throes of psychosis. We should not be shocked when an inpatient in a psychiatric ward attacks and harms a staffer. If society should be shocked and enraged at anything or anyone, it should be the system that failed to properly manage serious mental illness in the community.
What we need to do as a society is stop denying the truth that psychosis can be deadly – and when something terrible happens, reconcile to what we knew in advance instead of giving ourselves an excuse to act out with vengeance. Instead, societies need to build social policies and criminal justice upon a foundation of what medical science knows to be true about SMI.