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Winter 1995
   
Treating Insanity Reasonably
Sally Satel
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Juan Gonzalez, a 43-year-old Bronx man with a history of mental illness, thought he was under orders from God when he boarded the Staten Island Ferry in July 1986 and began slashing at the crowd with his sword, killing two and wounding nine. Two days earlier, doctors at Columbia-Presbyterian Hospital's psychiatric emergency room had examined Gonzalez and released him on his promise to seek outpatient care.

In the ensuing years, such incidents have become ever more familiar. Recent front-page murderers like Jorge Delgado, Christopher Battiste, and Kevin McKiever were all clinically psychotic when they killed; like Gonzalez, none was a stranger to the mental health system.

These people are the most horrifying legacy of deinstitutionalization, a process that shrank the population of New York State's mental hospitals from 93,000 in the fifties to 9,000 today. While many of those who left the hospital did not need to be permanently committed, a large subset of them proved unable or unwilling to continue their treatment and drifted into a life on the margins—a life of homelessness, addiction, and, in the worst cases, violence. An estimated 10,000 untreated mentally ill homeless today wander the streets of New York City. Additionally, as many as 10 percent of state prison inmates suffer from a serious psychotic disorder.

In the early days of deinstitutionalization, psychiatrists believed that voluntary treatment within the community was the best approach to virtually all mental illness. But voluntary treatment has proven to be far from a panacea, and most psychiatrists now agree that some patients must be forced to accept treatment.

New York State, however, makes that very difficult. Unless a patient is on the brink of violence—or has already acted violently—the state has very little ability to control him. Even weaker is the state's capacity to compel treatment for those who are profoundly disabled but not clearly dangerous.

It is time for New York to reform its policy toward the mentally ill. First, the state should make it easier to commit patients who cannot live on their own. Second, it should develop a system of compulsory "outpatient commitment." Third, it must improve the quality of services provided within the community, so that those with less severe illnesses can get the treatment they need.

New York State's mental hygiene code authorizes involuntary commitment of patients who have "a mental illness for which immediate...treatment...is appropriate and which is likely to result in serious harm to self or others." Although judges have interpreted this provision in different ways, the only people for whom it unambiguously allows commitment are those with a fully formed plan to kill themselves or others and those literally caught in the act.

Not surprisingly, admitting a resistant patient to the hospital is usually an uphill battle for psychiatrists. Dr. Michael Allen, who supervises the admission of psychiatric patients at Bellevue, says that whenever his psychiatrists pursue commitment, they gird for a struggle with the patient's lawyer and the judge who will preside over the hearing. Because many lawyers and judges have a profound mistrust of psychiatry, rooted in the ideology of the sixties, what should be a collaborative effort to arrive at a legal decision about what's best for the patient instead becomes an adversarial challenge, with the patient's lawyer arguing for his client's release. "Lawyers may view it as similar to a criminal proceeding, with the goal being to avoid incarceration, not to look out for the person's best interest," Allen says.

The judges who rule on commitment also view the hearings as if they were criminal trials, in which the patient must be afforded every opportunity to preserve his liberty. In this context, judges are often reluctant to rely on information from the patient's family, friends, or even his personal doctor—the people most familiar with the patient's pattern of deterioration. Those closest to a patient may know, for example, that he regularly becomes sleepless and agitated several days before a full-blown psychotic episode. But often he must advance to a stage of wild psychosis or violence before a judge will authorize involuntary treatment. "Judges have an aversion to weighing facts about the patient's clinical history," Allen says. "To them, this seems prejudicial." This attitude persists in spite of a recent ruling that allows judges to consider the natural course of an illness and the patient's history of failing to comply with treatment in commitment determinations.

Similarly, though some judges have interpreted the "dangerousness" standard for commitment broadly enough to allow hospitalization of patients whose self-destructive behavior falls short of attempted suicide, many have construed it narrowly.

The state should codify a more enlightened standard, joining 39 other states by adopting "grave disability" rather than "dangerousness to self or others" as the criterion for commitment. This standard allows involuntary hospitalization of mentally ill people who are at significant risk because they are neglecting their basic needs, including food, clothing, shelter, health, and safety.

For a vivid illustration of the need for such a standard, consider the case of Mr. B., a patient I treated as a resident psychiatrist several years ago. Mr. B., a homeless man living on the streets of Manhattan, suffered from schizophrenia. Emaciated and dehydrated, he refused to eat because he thought the CIA was poisoning his food. The owner of a local package store allowed Mr. B. to sleep in the basement for $5 a night, but Mr. B. couldn't afford to pay after he began using all his panhandled change to phone the White House operator and complain about the CIA. He started sleeping on the freezing pavement outside the store; instead of eating, he began stuffing newspaper in his mouth, declaring: "The words will feed my soul."

Concerned, the store owner offered to take Mr. B. to the emergency room. When Mr. B. refused, the owner called the police as well as the psychiatrist on duty at the local hospital, asking them to take Mr. B. to the hospital. Was Mr. B. planning to kill himself or harm others? they asked. If not, they were powerless to do anything.

Mr. B. became suspicious of his benefactor and fled the neighborhood. His toes became frostbitten, and he wanted to see a doctor. He began limping to a local emergency room but became frightened and turned back when he decided that the doctors must be under CIA control.

Soon, Mr. B. collapsed in the street and was brought to a hospital, where doctors removed his gangrenous toes. Finally, in order to be closer to his son, he was transferred to the Connecticut hospital where I worked. Because Connecticut has a grave disability standard, the hospital was able to retain him for treatment. That Mr. B.'s deterioration had to reach such an extreme—and that he had to leave New York State—before he could receive the treatment he desperately needed is a tragic indictment of the state's mental health system.

A grave disability standard would be enormously helpful to emergency room psychiatrists seeking to help desperately ill patients. But in 1994, the New York State Legislature rejected a bill that would have written the grave disability standard into law. One of the chief opponents was the New York Civil Liberties Union, which charged that the new standard would be an unconstitutional abridgment of personal liberty. This argument is both legally and philosophically indefensible. The U.S. Supreme Court has never barred states from committing gravely disabled patients. And even John Stuart Mill, the father of libertarian thought, recognized that normal ideas of liberty do not apply to individuals whose state of mind is "incompatible with the full use of reflecting capacity." Freedom of choice is an empty notion for those whose minds are paralyzed by psychotic delusions.

Opponents of institutionalization contend that the problem is not the difficulty of hospitalizing the mentally ill against their will but rather the difficulty of obtaining meaningful treatment for the mentally ill within the community. This argument is half right. Not all patients need to be committed; some who are committed can eventually be released. But it is often impossible for patients to sustain the gains they have made in the hospital, whether they entered voluntarily or not, if they fail to complete their treatment after discharge.

Part of the problem is inadequate services, but at least as big a part of it is that many patients don't follow through on their treatment, and the state lacks the legal muscle to force them to do so. An estimated half of mentally ill patients fail to take their prescribed medications regularly; some never take them. Among the homeless, the rate of compliance is even worse.

The biggest obstacle is that the mentally ill often don't understand that they need to take their medicine. In a recent study published in the Archives of General Psychiatry, more than half of schizophrenic patients examined were either completely or largely unaware that they even had a mental disorder. Such individuals often follow a revolving-door pattern: when they go to the hospital, they quickly stabilize on medication, but after release they stop taking medication, deteriorate until they become overtly psychotic and ultimately dangerous, and are again committed to the hospital.

The state should have the power to force such patients to complete their treatment outside the hospital. Outpatient commitment, as the approach is known, would be consistent with the spirit of New York's mental health laws, which require courts to place patients in the "least restrictive clinical environment" suitable for their needs. Only if a patient violated the terms of outpatient commitment—that he take his medicine and see his psychiatrist or social worker regularly—would he face involuntary hospitalization.

Until 1994, New York was the only state where the law specifically barred compulsory treatment in the community. But the State Legislature has enacted a bill, sponsored by Senator Frank Padavan and Assemblywoman Elizabeth Connolly, creating a three-year pilot project to test outpatient commitment. Beginning in July 1995, the program will enroll patients about to be discharged from Bellevue who are "incapable of surviving safely in the community without supervision" and have been involuntarily hospitalized at least twice in 18 months after failing to complete treatment.

Although this pilot project is quite modest, it is a significant first step. Bills authorizing outpatient commitment statewide had regularly failed in previous years, the result of intense lobbying by civil libertarians and some groups representing former mental patients. Pilot status seemed to make the provision more palatable to such groups; the New York Civil Liberties Union took no position on the 1994 legislation. Others, however, opposed even this moderate measure. The Mental Health Association in New York State argued that involuntary services are more expensive than voluntary ones—a true but meaningless claim. The proper comparison is outpatient commitment versus expensive revolving-door treatment: repeated ambulance rides, emergency hospitalization, and occasional trips to jail.

Dr. Joel Dvoskin, an associate commissioner in the New York State Office of Mental Health, criticizes outpatient commitment on the grounds that its effectiveness results from the intensity of the treatment, not its compulsory nature. He argues for more intensive case management in community-based programs.

But, as Dr. Luis Marcos, New York City's commissioner of mental health, recognizes, the mentally ill need both better case management and compulsion. Some patients, he has said, simply need the "weight of the court and the knowledge that if they don't take their medication, they would end up back in the hospital."

The most irresponsible criticism of outpatient commitment comes from an Albany-based group, Disability Advocates. Its critique states: "African-Americans and Hispanics are more likely to be subject to the force of outpatient commitment than white persons." This racialist argument ignores the fact that outpatient commitment is in the interest of the patients themselves. Studies have shown that, once treated, patients often realize that coercion was in their best interest. The danger of going untreated is palpable. A recent study published in the journal Hospital and Community Psychiatry found mental patients four times more likely to be victims of homicide and three times more susceptible to accidents than the general population.

On one topic, supporters and critics of coerced treatment both agree: Community-based treatment programs in New York State are woefully inadequate. The State Office of Mental Health estimates that one-third of all discharged patients are lost to the system, a euphemism for back on the street or in prison. While the number of beds in state psychiatric hospitals has declined by about 60 percent since the early eighties, the number of state prison cells has more than doubled.

The state needs comprehensive services for the seriously mentally ill—aggressive outreach to bring people into the mental health system, greater staffing of crisis centers in emergency rooms and outpatient clinics, and supervised housing and treatment programs. Ideally, social workers, under the supervision of psychiatrists, should serve as case managers, taking full responsibility for eight to ten patients, getting them the treatment they need, and monitoring their progress daily. If a patient has a track record of poor compliance with treatment, his caseworker could invoke outpatient commitment. Such a system functions well in Massachusetts, Michigan, New Hampshire, Wisconsin, and elsewhere.

In New York, the State Office of Mental Health hopes to initiate a case-management service in the form of a managed-care network serving some 35,000 severely mentally ill recipients of Medicaid. The program would guarantee access to housing programs, social workers, and outpatient services. But because it is designed for voluntary patients only, it would probably be ineffective in serving the severely disturbed people currently on the streets, who are notoriously resistant to treatment.

Currently, in New York, the severely mentally ill find themselves in the center of a vicious fiscal cycle. Albany is shutting down mental hospitals—by 1999, it plans to close 5 of the 22 it currently runs and shrink most of the others, reducing the number of beds from the current 9,000 to 6,000. Under the Community Mental Health Reinvestment Act of 1993, the state plans to shift about $58,000 into community care for each hospital bed it eliminates.

But the money that is to become available, when compared with what the state already spends on community care, is just "a drop in the bucket, assuming it even hits the bucket," according to a policy analyst in the state government. The Office of Mental Health plans to spend $790 million on outpatient care in 1995; reinvestment will free up an additional $40 million. The analyst estimates that the state needs at least $400 million more to create an outpatient system like those that have been successful in other states. This may be an overstatement: many of the programs the state supports simply don't work, so it could make substantial improvements by spending existing funds more wisely. The election of a new governor committed to cutting taxes may force the state to find ways of making better use of the money it has. It's indisputable, however, that effective, intensive treatment is quite costly.

Moreover, the success of the Reinvestment Act depends on the timely closing of empty hospitals. Because hospitals are major employers in small upstate communities, local politicians and unions fight hard to keep them open. The Gowanda Psychiatric Center near Buffalo had been scheduled to shut down several times beginning in 1991 but was not finally padlocked until April 1994, after a long and expensive death watch. The state spent $2.9 million in 1993 to keep the staff and only 14 patients on the premises.

The need for more services should not obscure the need for effective laws allowing psychiatrists to treat the seriously mentally ill against their will. Reducing the number of hospital beds makes sense only if doctors can compel their patients to complete treatment in the community. If outpatient commitment becomes a real option, 6,000 beds should be enough to serve those who truly need to be institutionalized. If it does not, the state will have to repopulate its mental institutions or else continue allowing the homeless mentally ill to wander the streets, endangering themselves and, in some cases, others.

Civil libertarians and some mental health advocates argue that current law is fine; New York State just needs more community services. In truth, the state needs more laws and more services. Today, thousands of people with severe mental illnesses roam the streets of New York, their "right" to liberty intact. But the freedom to be crazy is no freedom at all, as many of these people—once treated—will attest.

 

 

 
It’s no favor to let former mental patients lead desperate lives on the streets. Here’s a psychiatrist’s plan to get them the care they need.
City Journal Winter 1995.
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