James Pavle, executive director of the Treatment Advocacy Center in Arlington, Virginia, writes a pretty strong indictment regarding the issue of treatment for mental illness in The USA Today. He calls it the “criminalization of mental illness.”
The USA continues, “Imprisoning people acting on symptoms of mental illness isn’t good for the people, law enforcement, jails and prisons or anyone else, and there is a sane alternative: court-ordered outpatient treatment. Involuntary treatment in the community has been found to lower arrest and incarceration rates – and costs far less than jails, hospitals and emergency rooms.”
It is within this context that we must understand Rich Rifkin’s column, arguing a legal decision, in which he demonstrates a lack of common sense.
It seems that a three-judge panel of the Ninth Circuit Court of Appeals made a ruling last week that prison doctors cannot forcibly medicate an inmate. Writes Mr. Rifkin, “From a legal perspective, perhaps it was the right decision.” However, he adds, “From a common-sense standpoint, this decision is nuts. It does not improve Loughner [Congresswoman Gabrielle Giffords’ attacket]. It does not help his jailers. It does not serve our society.”
It is not hard to disagree with Mr. Rifkin’s focus here. If Mr. Rifkin wants to argue that this decision did not help Mr. Loughner, the guards, or society, he is partly right. But the solution is not to forcibly medicate people like Jared Lee Loughner, the solution is to get him out of prison altogether and into the kind of facility that can actually treat him.
Mr. Rifkin makes several other key points here, “Our country would be better off if the judges and attorneys would leave the doctoring to the doctors. The only pertinent question a judge needs to ask in this case is whether board-certified psychiatrists agree on the diagnosis. If so, let the medical professionals decide his course of treatment.”
But would we? Having actually observed trials, I do not have a lot of faith in board-certified psychiatrists running independently of the wishes of the courts and other powers that be.
He continues, “Common sense suggests that when a patient is out of his mind and is dangerously violent, he needs to be forcibly treated.”
But what evidence is there that Mr. Loughner is out of his mind and needs to be forcibly treated? As he himself pointed out, Mr. Loughner has not even been found guilty of a crime.
He continues, “The fact that Loughner has not yet been found guilty of a crime is irrelevant when it comes to his civil liberties. He is a severely ill, violent, paranoid schizophrenic. That is more than enough to take away his civil liberties.”
The real question is who gets to make that determination.
In fact, it becomes clear that Mr. Rifkin really has no interest in protecting Mr. Loughner at all. He admits appallingly, “I wouldn’t be sad at all if he killed himself in prison. But as long as he is the responsibility of the federal prison system, it is crazy to suggest that a man who is out of his mind should decide if he wants to take his medications or not.”
Mr. Rifkin ignores some critical points, including a history where people under the direction of the same board-certified psychiatrists were unnecessarily drugged and lobotomized.
It is Eric Gelber, who, unlike Mr. Rifkin, has training in this area who makes the point, “The court noted that he has not been convicted of a crime, and is presumptively innocent. Forcible injection of medication into a nonconsenting person’s body, the U.S. Supreme Court has held, represents a substantial interference with that person’s liberty.”
Indeed, in this case, as Mr. Gelber points out, “The court notes in this case that the state’s asserted interest in protecting Loughner and others around him from harm is somewhat remote. No one contends that he’s a danger to himself, and the state has managed to keep him in custody for more than six months without injury to anyone.”
So, what exactly is the compelling interest that Mr. Rifkin has in opposing the ruling of the court here?
Mr. Gelber continues, “Keep in mind that the principle enunciated by Rifkin – let doctors have unfettered discretion when it comes to forced medical treatment – would apply even to individuals accused of crimes far less egregious, and to cases where the facts are not as apparently cut-and-dried as in this instance. To those of us who value our civil liberties, that not only lacks common sense, it’s frightening.”
I tend to agree. The reason the courts have ruled as they have is past practices. If Mr. Rifkin strips away that protection, what recourse do prisoners have when industry doctors recommend forced medication?
Mr. Rifkin responds, “The problem with Gelber’s entire argument… is that he presumes that Loughner can make a rational decision about his own health care.”
I do not see it that way. I see Mr. Gelber’s argument being that the state must have a compelling interest to force medication and this case does not rise to that level.
Mr. Rifkin continues, “The biggest problem for the seriously mentally ill in most of the United States is that the civil libertarians, who don’t care how much destruction their ideology causes, is [sic] that people like Loughner are not getting effective treatment from psychiatrists before they cause mayhem to themselves or to others.”
On the contrary, I think the letter printed in the USA Today really strikes at the heart of the issue. We have criminalized mental illness and we put mentally ill people in prison rather than in the kind of treatment facilities they really need. And we do this despite the fact it is actually cheaper to treat people than it to incarcerate them.
The problem that I see with Mr. Rifkin’s views is that he looks at the situation from a very black and white perspective, thus he writes, “So yes, if we would forcibly medicate the paranoid schizophrenic who has not yet murdered anyone, but say has just committed simple assault, we would be far better off, and so would the patient. But doing so contradicts the ideology of the extremist civil libertarians who don’t ever let common sense or common decency get in their way.”
The problem with that is who gets to determine this. When doctors are placed in the position of being judge, jury and executioner, there is a real danger that they will begin acting upon the interests of their employers. This is why that decision was placed into the court’s authority in the first place.
There need to be legal standards and due process of law to guide these decisions.
So, Mr. Rifkin completely missed the boat when he writes, “It’s unfortunate that on this issue Loughner is represented by lawyers. Our country would be better off if the judges and attorneys would leave the doctoring to the doctors.”
No, Mr. Rifkin, the job of the lawyers is to protect the legal rights of people like Mr. Loughner. The job of doctors is to determine the best course of action, medically, for a patient. When both work together to determine the best interests of the individual, both legally and medically, that is when the world works best.
The world that Mr. Rifkin suggests is public safety over all else, even at the expense of civil rights, and Mr. Rifkin admits he doesn’t give a damn about the well-being of Mr. Loughner. It is clear that he is the last person who ought to be making this decision.
—David M. Greenwald reporting
I can remember when a teen-age friend was committed to a mental hospital by his family because his father saw him with “a suspected homosexual artist .” He was subjected to ice-water baths, electro-convulsive therapy and drugged with Thorazine when he refused to admit that he was gay .
Some what more recently, a young friend was unable to get care in Sacramento until he attempted suicide after months of trying to get medical assistance through the county . This is the messy human element of public policy and budgetary priorities !
With regard to Rifkin’s comment ” Our country would be better off if the judges and attorneys would leave the doctoring to the doctors.”
Speaking as a doctor, I would like to say that I agree with this assessment. However, history would seem to indicate that doctors as a group are no more likely to act ethically than any other group of people. Well known examples of doctors not acting in the best interest of their patients or charges or society as a whole include Joseph Mengele,the multiple physicians involved in the Tuskegee Syphilis Experiment or more recently Dr. Kamrava the Reproductive Endocrinologist who gave us the Suleman octuplets. What would seem to be common sense, leaving medicine to the medical experts without any kind of regulation can have unintended adverse consequences for which we all pay.
Medwoman: In a lot of trials, there are doctors with divergent points of view, often corresponding to who hired them. Every so often the prosecution’s doctor agrees with the defense. But when medical views diverse, who decides? In the end, it is still the court making the determination which doctor is right. I don’t see any way to avoid this dilemma.
David,
Nor do I. I certainly do not pretend to know what the “best” solution is. Only that I am very certain that there does need to be some balance between one medical perspective and the civil rights of the individual which unfortunately do not always coincide. Rifkin’s article paints this dilemma in terms which are far too black and white. I am quite sure he sees more complexity than his article would suggest.
Rich, would you like to comment further on your view ?
[quote]On the contrary, I think the letter printed in the USA Today really strikes at the heart of the issue. We have criminalized mental illness and we put mentally ill people in prison rather than in the kind of treatment facilities they really need. And we do this despite the fact it is actually cheaper to treat people than it to incarcerate them.[/quote]
I think to a certain extent, this comment misses the real issue by a mile. Here is the dilemma, from my limited perspective in having worked with a mentally ill person. I had a case involving a mentally ill individual, who thought little green men were coming through the vents and ductwork of her apartment. She would wake up in the middle of the night, wander the apartment complex banging on doors, trying to warn everyone of impending doom from the invaders. For understandable reasons she received an eviction notice from the landlord.
I sought out expert legal assistance, and together legal aid and I successfully fought the eviction, which was technically defective from a legal standpoint. However, I perfectly understood if this woman did not get assistance of some sort, there was no way that she could remain in the apartment complex. And then she would be homeless and on the streets. So I rounded up mental health services (MHS) for this woman. She was paired with a social worker from MHS, given an in-home supportive services worker to dole out her psychiatric meds and perform various basic functions so this woman could still live independently and not be institutionalized. She also was able to attend Yolo Adult Day Health Care several days a week for some supervised care. We also worked closely with family members, who were doing their level best to help in whatever way they could.
The woman fought being medicated tooth and nail, bc it made her very sleepy. She hated the side effects of medication. However, w/o the meds, she would end up institutionalized. Eventually my client was convinced to follow the drug regimen subscribed, and she improved dramatically. But unfortunately, as soon as she “got better”, she would stop taking the meds, feeling she no longer needed them. Of course she would start acting out irrationally, and the whole cycle would start over again. It was frustrating to watch, and devastating to her family.
Ultimately the woman was bounced from place to place, and eventually ended up at Eleanor Roosevelt Circle (ERC) in Davis. The advantage to ERC is that it has an excellent on site Social Services Director who is specifically charged with dealing with difficult residents like this woman. But even there, certain rules must be enforced for the sake of all residents. At some point I heard that my client passed away.
The point of my story is to explain how complex this issue is. Mentally ill people often need to take their medications to remain in society (including prison society), and if they will not cooperate, the only solution may be institutionalization. So which is better – forcing medication so that the person can remain freer and more unfettered to carry on a fairly normal life outside the walls of an institution, or let them make the choice of failing, and then force them into institutions where they have no freedoms?
I don’t have any good answers, and would not presume to offer any here. I am not an expert in this field, but really do understand some of the dilemmas that make this an intractable, difficult problem. I don’t necessarily think Eric Gelber or Rich Rifkin are right or wrong on this issue. It is a matter of perspective, and this is a problem w no really good solution…
Elaine,
I thank you for sharing this story. During my internship in Fresno I was witness to another, more tragic example. A 10 year old boy was brought into the Emergency Room bleeding to death from multiple stab wounds to the chest. The wounds had been inflicted by his schizophrenic mother who thought he was the devil and that she was protecting her son and herself from him. I agree that there are no easy answers here, but to those who do not believe that there is any personal obligation to help those around us when we witness someone in apparent need, I would point to Elaine’s story as an example of when it truly does take the community coming together for all of our well being. I cannot help but remember and wonder even thirty years later if that boy might have been alive if someone had intervened as you chose to.
[quote]I thank you for sharing this story. During my internship in Fresno I was witness to another, more tragic example. A 10 year old boy was brought into the Emergency Room bleeding to death from multiple stab wounds to the chest. The wounds had been inflicted by his schizophrenic mother who thought he was the devil and that she was protecting her son and herself from him. I agree that there are no easy answers here, but to those who do not believe that there is any personal obligation to help those around us when we witness someone in apparent need, I would point to Elaine’s story as an example of when it truly does take the community coming together for all of our well being. I cannot help but remember and wonder even thirty years later if that boy might have been alive if someone had intervened as you chose to.[/quote]
Thanks for sharing your sobering story. And I could not agree w you more that it does take a community (village) to address the mental health issues of those afflicted in this way. I cannot say enough about how much help I had in assisting this poor woman – help from legal aid, MHS, APS, IHSS, the family of my client. I am nothing more than an attorney, who was faced with an eviction problem. But I recognized that more assistance was needed than what I could possibly give her. As soon as the landlord got the eviction procedure right, my client was going to be out on the street – and to some extent rightly so. You cannot have a tenant banging on doors at 2 am in the morning, ranting about men from space ships coming to get everyone!
When I reached out to APS, IHSS, MHS, I got nothing but tons of support. I think one of the joys of working in a small county is the fact that everyone knows everyone else. In that interconnectedness is the county’s strength. We know where to turn to for help outside our area of expertise.
And medwoman is so right – if that mother had gotten the mental health help she needed, would her son be alive today? Of course we can never know for sure, but it would have been nice to have at least tried. And should the mother have been made to take her meds? I don’t know the answer to that question. I don’t think there is a simple answer. Would the meds have worked? Assuming they worked, and she refused to take them, would it have been in her best interest to force them on her? Perhaps, perhaps not. Think about it. If she was forced to take them, she may have been lethargic and non-functional all the time. If she refused to take them, she could have been threatened with institutionalization, but only if she qualified. What if she didn’t qualify? If she were institutionalized, what would have happened to her son? So many questions, w no good answers.
I honestly think mental health issues have to be dealt w on a case by case basis. One size/solution does not necessarily fit all. What I do know is that our current mental health services are woefully underfunded, and prisons are becoming the defacto placement for those mentally ill who cannot conform their behavior to what is acceptable in society. But where the heck does that money come from for mental health services? Mental health services is very labor intensive, expensive, time consuming work. Not many people want to deal w the mentally ill on the front lines. And it takes commitment by those who really understand the problem, but also by those who don’t understand the problem but want a better, more humane world where everyone gets a chance to work up to their fullest potential.
Sorry, I’ll get off my soapbox now…
[i]“Rifkin Wants Doctors to Have Ability to Force Medicate Patients Without Due Process of Law”[/i]
This is a dishonest and unfair headline. I never said I do not want “due process of law.” I just strongly disagree with the process that now is in place.
Here is the due process which I believe best serves justice in a case such as that of Jared Lee Loughner:
Have the judge in charge order a psychiatric evaluation. That was done here. Have the court-appointed psychiatrist give his diagnosis to the court. That was done here. Have the judge ask these questions upon receiving the diagnosis:
1. What is your recommended course of treatment? (The psychiatrist would then explain what drugs and counselling and so on he recommends.)
2. In your professional opinion, would the patient be better off or worse off with this course of treatment? (Better off.)
3. In your professional opinion, would the patient be better off or worse off with no course of treatment? (Worse off.)
4. Given the defendant’s mental illness, do you believe he is competent to direct his own course of treatment. (Not competent.)
At that point, I think the judge should have to start the process over with another, independent board-certified psychiatrist who can do his own diagnosis and answer the same set of questions of the judge.
If at that point both doctors agree on the diagnosis, the course of treatment and the incompetency of the defendant, the judge should authorize the doctors to do what they believe is in the best interest of the patient.
To me, that is due process.
[i]” Instead of hospitalizing people with mental illness, many are jailed or imprisoned.”[/i]
It’s important to understand that no one is jailed or imprisoned for his severe mental illness. The psychotic is jailed for his crimes, which may be petty or may be heinous. And those crimes committed by the severely mentally ill in most many cases would have been avoided if we had authorized the patient’s family to order medical intervention where the patient was treated by a board certified psychiatrist.
[i] “By some estimates, 16% of inmates are suffering symptoms of severe mental illness.”[/i]
Here are the numbers from the Bureau of Justice Statistics ([url]http://bjs.ojp.usdoj.gov/index.cfm?ty=pbdetail&iid=789[/url]): [quote] Nearly a quarter of both State prisoners and jail inmates who had a mental health problem, compared to a fifth of those without, had served 3 or more prior incarcerations. Female inmates had higher rates of mental health problems than male inmates (State prisons: 73% of females and 55% of males; Federal prisons: 61% of females and 44% of males; local jails: 75% of females and 63% of males). Over 1 in 3 State prisoners, 1 in 4 Federal prisoners, and 1 in 6 jail inmates who had a mental health problem had received treatment since admission. [/quote]
[i]”But the solution is not to forcibly medicate people like Jared Lee Loughner, the solution is to get him out of prison altogether and into the kind of facility that can actually treat him.”[/i]
Jared Loughner killed 6 people and wounded 13 others, some very seriously. David Greenwald is living on a different planet if he thinks Loughner will ever be out of the prison system.
Also, Greenwald does not seem to understand where Loughner is: he is in a locked medical facility, not a regular prison. It’s the federal medical facility in Missouri, which is similar to what the Vacaville Medical Facility originally was. Loughner has no exposure to regular federal inmates.
That said, I believe in the old-fashioned verdict of not-guilty by reason of insanity. It still exists, but rarely happens any more. In a case like Loughner’s, I think justice would be best served if, after a trial or a plea, he would be locked up in a secure insane asylum for the rest of his life (much like John Hinckley, the schizophrenic who shot Reagan).
[i]“But what evidence is there that Mr. Loughner is out of his mind and needs to be forcibly treated?”[/i]
The evidence that Mr. Loughner is out of his mind is extremely strong. Not only have six psychiatrists (in two teams of three, one team in Arizona and another in Missouri) diagnosed him as a paranoid schizophrenic with hallucinations and delusions (as reported in the NY Times), but his actions (the shootings) and his behavior (getting kicked out of Pima CC) make that abundantly clear.
Because Loughner also has been diagnosed with anosognosia, he lacks insight into his illness. It is only in those cases where psychiatrists order forced treatment.
[i]“So, what exactly is the compelling interest that Mr. Rifkin has in opposing the ruling of the court here?”[/i]
The compelling interest is the patient’s and society’s. Both are better off is he gets medical treatment. Both are worse off if he goes untreated. In fact, even an extremist like Eric Gelber does not argue that Loughner is better off without psychotropic drugs which are safe and effective according to the best medical science.
[i]“If Mr. Rifkin strips away that [u]protection[/u], what recourse do prisoners have when industry doctors recommend forced medication?”[/i]
Here Greenwald is clearly wrong: he assumes that Loughner is being protected? How is not treating a person’s severe mental illness protecting him? It is not. Loughner is protected by getting good medical treatment from good, well-trained doctors.
[i]“I see Mr. Gelber’s argument being that the state must have a compelling interest to force medication and this case does not rise to that level.”[/i]
The compelling interest is clear: the patient is better off getting medical treatment, and society is better off if the patient is not insane.
[i]“We have criminalized mental illness and we put mentally ill people in prison rather than in the kind of treatment facilities they really need.”[/i]
These are two distinct statements: one true, one false. We have not criminalized mental illness. Rather, we stopped forcibly treating mental illness and the result has been a lot of homelessness for the mentally ill, and in some cases those untreated mentally ill committing crimes ranging from the petty to the heinous, which result in them in jails and prisons.
The second statement of yours I agree with: those seriously mentally ill patients who do not get treatment because they cannot run their own lives due to the mental illness need to be “put .. in the kind of treatment facilities they really need.”
Sadly, we no longer even have public mental asylums to house them, thanks to the ACLU and their ideological brethren who worked so hard to empty them back in the 1960s and 1970s.
Fortunately, the drugs available today to treat schizophrenia are so good that we really don’t need to lock up many patients for treatment. If we would fund and enforce Laura’s Law, which was written by Helen Thomson of Davis, we could handle most forced treatment on an outpatient basis.
[i]“When doctors are placed in the position of being judge, jury and executioner, there is a real danger that they will begin acting upon the interests of their employers.”[/i]
Utter nonsense. I never called for any doctor to be a judge or a jury or an executioner. I want judges to rely on independent, well-trained doctors, always more than one for a second opinion, to determine the best course of medical care. If you can show me a single case in the last 25 years where multiple board-certified psychiatrists made the wrong diagnosis of schizophrenia and ordered the wrong course of treatment which harmed the patient/defendant, I will eat my hat. The truth is, you and the civil libertarians pretend we have an epidemic of abusing psychotic patients with too much medical care, when the reality is just the opposite.
[i]“There need to be legal standards and due process of law to guide these decisions.”[/i]
I have never once suggested we do not need a due process of law. I just question the process we now have, because it harms the interests of society and the patient.
[i]“No, Mr. Rifkin, the job of the lawyers is to protect the legal rights of people like Mr. Loughner.”[/i]
No, Mr. Rifkin?! Where did I say that was not the job the lawyers were doing? I say their doing that is the problem, because the result is their client is not being medically treated as his doctors believe would best serve him. If you can show me medical literature which suggests that treating a patient like Loughner with an atypical antipsychotic like Risperidone, Olanzapine, Quetiapine, Ziprasidone, Aripiprazole or Paliperidone is not medically beneficial or is more harmful than no treatment, I will agree with you. But you have failed to prove your case: that the doctors treating Loughner are not acting in his interests.
[i]“The world that Mr. Rifkin suggests is public safety over all else, even at the expense of civil rights …”[/i]
I don’t agree with that. I do think there is always a balancing act. Unlike you, I am not an ideologue. I apply common sense and decency and reach my conclusions. Yours are guided by extremist civil libertarianism, which leads you to conclusions that harm society and harm individuals in order to maintain your extremist standards.
[i] “… and Mr. Rifkin admits he doesn’t give a damn about the well-being of Mr. Loughner.”[/i]
That is not true, either. I said I would not be sad if he killed himself, because his crimes were so horrific. I feel the same way about all mass murderers. Nonetheless, I believe very strongly that as long as he is in custody and is the ward of our medical facility, he deserves a proper course of treatment which would help him recover his sanity as best as is possible.
[i] “It is clear that Rifkin is the last person who ought to be making this decision.”[/i]
Absolutely. I never suggested I should be making Loughner’s medical care decisions. I think he needs trained, professional, board-certified psychiatrists acting on his behalf to choose his course of treatment, because he is not competent to do so. I think the courts need to give the doctors that authority, based on the questions I laid out above.
[b][quote]”Rifkin Wants Doctors to Have Ability to Force Medicate Patients Without Due Process of Law”[/quote][/b]
Funny, I didn’t get this from Rich Rifkin’s column and subsequent comments. If you insist on using words he didn’t use, how about “Rifkin Wants Due Process of Law to Allow Doctors to Have Ability to Force Medicate Patients”?(“Suffering with Severe Psychoses Whose Lives or Others’ are in Jeopardy,” I’d add.) In fact, Rich acknowledged that the decision perhaps was right “from a legal perspective.”
As Elaine, bidden and madwoman point out, “it’s complicated.” It’s also not convincing to use history as a guide to present law and medical knowledge and capabilities. Just because judges used to determine “guilt” in medieval ways or because Reagan closed facilities that treated mental illness and disorders or because doctors used forced lobotomy as a treatment in the past–doesn’t mean their counterparts won’t make better decisions now.
The decision Rich charges “lacks common sense” is a good case study on the need for changes in the law. Why lawyers, judges and the law itself forces Mr. Loughner to avoid modern medical treatment (thereby allowing him to maintain his certified insane status and avoid facing trial with a fairly certain lifetime sentence) is a perfect example of attorneys placing strategy over the [u]real[/u] interests of the accused.
Times have changed. The odds that a untreated, severely ill, violent, paranoid schizophrenic will try to kill himself or others probably outnumber those that proven psychotropic meds/treatment will endanger him seriously with side effects.
I read the [u]USA Today[/u] Pavle nine-sentence op-ed–thanks again for providing a link–and I got a different take-away. The context, as you say, needs to include his solution (one that I think Rich would find much closer to his view than you want to suggest:[i][quote]”Imprisoning people acting on symptoms of mental illness isn’t good for the people, law enforcement, jails and prisons or anyone else, and t[u]here is a sane alternative: court-ordered outpatient treatment. Involuntary treatment in the community has been found to lower arrest and incarceration rates — and costs far less than jails, hospitals and emergency rooms[/u].”[/quote][/i]PS–I’ve had lots of trouble working with the [u]Vanguard[/u] website since installing the new MacOS. Don’t blame you at all, but maybe Hathway Tech could take a look at the problem and do a fix at your end.
PPS–I see my post might have become outdated by Rich’s responses while I was struggling to get mine added. I’ll now go back to see if Rich makes any better points than David did on this very complicated issue.
Rifkin
I truly appreciate the depth of thought that you have put into this issue and agree with many of your points, especially those dealing with due process. I disagree however that it is possible for us to know what is in “the best interest”of another individual, especially one who has committed hoerdous acts while not in possession of their full mental capacity. I can see two instances in which it may not serve the persons best interest to be force medicated.
Take first the example of the mother who killed her son unknowingly. Whose best interest is being served if she is “successfully treated”against her will and has to endure the rest of her life knowing she killed her own son while attempting to defend him? is this really a compelling interest of the state, or might she be better served being hospitalized delusionally believing she had successful defended her family.
I don’t have an answer. Just pointing out that I don’t always think that we know the best answer for others.
The second thing that you do not address is the issue of side effects. All of the medications you site have the potential for serious and in some cases irreversible side effects. One of the major problems with treating psychotic patients as Elaine pointed out is that the side effects are frequently intolerable to the patient once they are lucid enough to recognize what is causing their symptoms. I think Elaine has the most accurate assessment of this when she states that when dealing with mental health issues, there is no one size fits all and each case must be judged on it’s own merits hopefully taking into account the values of the patient, rather than our own preconceived values as much as possible.
Oops …. Should have said horrendous acts……although hoerdous does have a certain ring to it ! Sorry Rich.
[quote][i]”I honestly think mental health issues have to be dealt w on a case by case basis. One size/solution does not necessarily fit all….prisons are becoming the defacto placement for those mentally ill who cannot conform their behavior to what is acceptable in society. But where the heck does that money come from for mental health services? “[/i][/quote]I’m also just catching up with you too, Elaine, and agree with your observations. But, contrary to the earlier premise, we are not “criminalizing mental illness,” but jailing guilty criminals who may or may not be able control their own actions.
The law needs to be changed in order for mental health to “be dealt w on a case by case basis.” This ruling may be overruled, yet current law seems to force the opposite, one-size-fits-all approach. The provisions Rich proposes would provide for the case-by-case approach.
That our law can require withholding treatment for someone crazy enough to have killed and crazy enough to avoid a trial because he’s mentally incompetent is just crazy itself. I’m not even sure that it’s not a violation of someone’s rights to withhold their trial on this basis when someone is “incompetent” enough to want to start taking responsibility for a terrible act.
When enough people decide change is needed, we’ll make the investment. And, we’ll more than repaid with what we save by not imprisoning those whose illness drives them to crime and those garden-variety, drug-users who go crazy during imprisonment. And, even those people who (consciously or not) got to jail just to have a home or to try to stop the voices.
One of the biggest concerns of parents dealing with mentally ill, or even mentally challenged, children is the fate they fear will befall the child at adulthood–let alone when the parents are gone–and society hasn’t a way to deal with their child except jails and prisons and bullets.
I knew I would get a lengthy response from Rifkin, I did not realize I would get his doctoral dissertation.
I don’t want to cut and paste response here, so I will make a few comments generally.
First, you can argue that you never explicitly said you do not want “due process of law” but I have little choice but to believe that is the implication of your policy proposal when you state the pertinent question that a judge needs to ask in this case is if psychiatrists agree on the diagnosis.
The problem with this view again is that that is not the only consideration from a legal standpoint. That’s why lawyers and judges are part of the legal remedy and doctors only advise.
The irony of course is that the due process you lay out is somewhat similar to what actually happens. The part where you seem to miss is that the court process is generally adversarial and so all of this process would be played out with competing arguments.
They have competency hearings in the existing system. People here are often sent to Napa. What you have not determined in your essay is where the current system, that remarkably operates as you lay out, broke down – at least from your vantage point.
The bottom line here is that what you describe is roughly the process but it did not yield the outcome you thought was the right one – why?
A few other responses:
“It’s important to understand that no one is jailed or imprisoned for his severe mental illness.”
No one is jailed or imprisoned directly for their mental illness, but the crimes they commit are as a result of that illness and thus the proper remedy would be to treat the underlying affliction (the mental illness) rather than the symptom (the crime).
In terms of the statistics, I think Robert Canning a few articles ago made a point about the measurement errors.
“Sadly, we no longer even have public mental asylums to house them, thanks to the ACLU and their ideological brethren who worked so hard to empty them back in the 1960s and 1970s.”
I think it’s a good thing that we no longer have such facilities which were generally abused and misused. The critical question to me is whether we can properly fund public mental institutions that give people appropriate treatment.
“Utter nonsense. I never called for any doctor to be a judge or a jury or an executioner.”
This is your rhetorical device. You never explicitly stated that, but that is the effect of instituting the insane asylum.
“I want judges to rely on independent, well-trained doctors, always more than one for a second opinion, to determine the best course of medical care.”
Don’t we all. The problem is not the intent, it’s the effect of the law and that troubles me.
“If you can show me a single case in the last 25 years where multiple board-certified psychiatrists made the wrong diagnosis of schizophrenia and ordered the wrong course of treatment which harmed the patient/defendant, I will eat my hat.”
I don’t think it would be that difficult for me to do it – however I lack the time and the impulse to do the research. There are multiple entry points of potential trouble, the first is at the initial intake phase where the original diagnosis is made. There are a lot of jurisdictions where indigent defendants do not even get competent representation in trial and now you are effectively creating a system that would subvert that. I lack the faith in the judicial system to be able to handle this equitably.
“The truth is, you and the civil libertarians pretend we have an epidemic of abusing psychotic patients with too much medical care, when the reality is just the opposite.”
I think we had an epidemic of abusing mentally ill patients, I think we currently have an epidemic of abusing indigent defendants and I’m not very interested in extending that power.
“I have never once suggested we do not need a due process of law. I just question the process we now have, because it harms the interests of society and the patient.”
Again, while I think you never stated it, in effect you have.
“I say their doing that is the problem, because the result is their client is not being medically treated as his doctors believe would best serve him.”
I think that’s an argument that heads down a quick slope to a world of problems. It would be like arguing that a defense attorney should admit to drug use in order to get the defendant medical treatment. There are in fact numerous times when defense attorneys argue for treatment as well but they and not you or I get to determine the best interest of their client.
“Unlike you, I am not an ideologue.”
I’m actually not an ideologue. I do have the core belief in less government in private lives. You do generally have to convince me that there is a legimate interest in the government interfering in private lives because in general they cause more problems than they solve.
Rich, you really should stop touting that BJS study as the best estimate of the prevalence of severe mental illness in prisons and jails. It was simply not methodologically sound and David’s estimate is closer to the “truth.” And I guarantee you that if I asked an inmate, as the BJS study did, if he/she saw a mental health professional or was treated for a mental health problem – not a serious mental disorder – in the last year, the number would be a lot higher than if I had a mental health professional do a full evaluation and counted that.
In the California prison system, about 23% of inmates participate in the mental health system. Of these, only about 12-13% would be considered to have a severe mental illness. What’s sad is that prison and jail are the de facto mental health system in the U.S. And that’s not how it should be.
Rich argues that the ACLU and others are responsible for emptying the state hospitals in the 60’s and 70’s. That’s partially true. But beyond that, it is not just the decline in state hospital population that has caused our public mental health system to be so lousy. The grand plan in the late 60’s and 70’s was for community mental health centers to care for individuals suffering from mental illness. But the money and infrastructure for community mental health never fully materialized and then Prop 13 came along in California and funds for these services became even scarcer. This was relieved somewhat in the early 90’s by “realignment” which gave some funds back to the counties, and then Prop 63 (the “millionaires tax”) provided some other funding streams, but community mental health has never been what it has needed to be.
And Rich is technically correct, individuals are not arrested for mental illness. But they might as well be. In the parole system, until lately, parolees with severe mental health problems routinely had their parole revoked if they missed doctor’s appointments or did not show up for groups in Parole Outpatient Clinic. And the then the court stepped in (see Valdivia v. Brown) and they couldn’t do that.
But Rich’s technical point misses the bigger picture. When the police or sheriff is called and recognize that the suspect is not acting normally, there are few options for them – Woodland Memorial inpatient is one – and the hassle of dealing with the mental health system as it is right now pushes the officer on the street to take the person to jail – and that’s the problem. Pre-charging diversion programs would help avoid this. Diversion programs at each step in the legal process are something that we need in Yolo County.
For several years the Local Mental Health Board, a citizens advisory group appointed by the Supervisors, has had as a goal a mental health court. It’s been difficult to get this going in the current environment, and surprisingly the shift of inmates to county custody will probably be the impetus to get programs like this going.
Decades of constitutional case law and statutory reforms have established that people with psychiatric illnesses have the right to choose the care they receive. Forced treatment is only appropriate in the rare circumstance when there is a serious and immediate safety threat—which, by the way, is not currently the case with Jared Loughner, and which is why the court’s decision in that case is not “nuts,” as Rich Rifkin suggests.
Forced treatment is counterproductive. Fear of being deprived of autonomy discourages people from seeking care. Coercion undermines therapeutic relationships and long-term treatment. The experience of forced treatment is traumatic and humiliating, often exacerbating a person’s mental health condition.
It is true that it is often difficult to engage people in treatment. But there are innumerable examples of successful service models that have developed effective techniques—including peer services, outreach, mobile outreach and supportive housing. All too often, systems turn to force and coercion because they lack such services. There is good evidence that assertive outreach programs can be just as effective as involuntary commitment provisions in getting the people to voluntarily take their medications. The research literature strongly suggests that, if mental health patients are provided with access to services on a voluntary basis, then society can accomplish the same ends without coercion, without the trauma of a court appearance, and without violating the individual’s right to make decisions about his or her own health care.
It’s often argued that the mentally ill do not take medications because they don’t know they are sick. In some instances, that may be so. But mental health patients may also have very rational reasons for not wanting to take these drugs. Even the newer antipsychotics have debilitating side effects, including extreme weight gain and drug-induced diabetes. Many people complain that they are spiritually deadening. They say that the drugs rob them of any sense of joy, of their willpower, and of their sense of being.
We should listen to consumer groups themselves—the voice of the people who would be subject to involuntary treatments. The vast majority are adamantly against involuntary treatment. They believe that such laws are a gross violation of their civil rights and argue that they are counterproductive, in that forced treatment drives people away from medical care.
The public has a greatly exaggerated sense of the dangerousness of the mentally ill. The reliance on forced treatment confirms false stereotypes about people with mental illnesses being inherently dangerous. But the risk of violence associated with major mental illness is small in comparison with the risk associated with such factors as substance abuse, for example. Holding up high-profile murders is a scare tactic—and is not a sound basis on which to base public policy.
There are no easy solutions. But it is unconscionable to focus on coerced treatment in an environment where we make ever deeper cuts and continue to take away what voluntary services are available. We should regard the use of forced treatment as reflecting a collective failure to provide adequate service, and to reform the system accordingly.
We need to focus on creating a more humane system, one that involves listening to consumer groups and providing people with mental health needs with good housing, vocational training and support, and other forms of social support. When services are offered voluntarily, without the threat of coercion, many will welcome antipsychotic medications, and take them readily. The answer for the rest is rarely coerced treatment. It is to respect people’s dignity and autonomy, and not dismiss their choices out of hand as the product of mental illness. And it is to provide alternative methods to help them cope. In those instances where intervention is necessary to protect health and safety, we need to provide the panoply of due process safeguards that have been developed over the last decades in response to abuses that were previously commonplace—and done in the name of providing humane care.
Eric
I found your post to be very well thought through and articulate. Do you work in the mental health field?
medwoman –
Thank you. Since you asked: I don’t work in mental health; although, I do have a Ph.D. in psychology and spent a few years doing teaching and research. But I left that field long ago to go to law school, in part due to what I viewed as the over-reliance on presumed psychiatric/psychological expertise in forensic settings. I spent 26 years as a disability-rights attorney for a non-profit disability rights organization. I now work as a policy committee consultant for the State Assembly.
I am going to drop out of this discussion. I lack the time and energy to argue with multiple people making multiple arguments against my point of view.
I will just close with this: I am perhaps unique among the group in this contentious argument, because I am perhaps the only person here who has dealt with this issue for a long time (about 20 years) with a close family member, who was for a good time a very close friend of mine as well, who suffers from untreated paranoid schizophrenia and anosognosia.
I have seen him in and out of mental health treatment where his major symptoms disappear in weeks when he is on the right prescription of aytpical antipsychotics*. But our system will not allow him to stay on those meds by force. Because he lacks insight into his own disease–he was actually a very sharp guy, though not highly educated–he always stops taking his meds and then he goes crazy and scares people and eventually winds up in jail or on the streets.
If an Eric Gelber or an RD Canning had my personal experience dealing with paranoid schizoprhenia, desperately but always failingly to get help for my family member, they would be singing a different tune.
There is an old saying that a conservative is a liberal who has just been mugged. I think my take on that is this: a civil libertarian ideologue, someone like Greenwald, would drop that extremist ideology if someone he loved had a serious disease like paranoid schizophrenia and the system he endorses prevented his loved one from really getting the treatment he needed due to “civil liberty considerations.”
*Medwoman is right about side effects. I know this from the complaints of my family member. He often suffered from drowsiness and listlessness. However, there are now many different, but similar acting atypical antipsychotics (that is what the newest class of drugs is called), and it does not take too long to find one, at the proper dose, which has minimal or manageable side effects. At the very worst, from my experience, a person suffering from psychoses is ALWAYS much better off with the psychotropics than without them. And he is better off still if he has the right drug for him at the right dosage. It is shockingly awesome to see someone who was out of his mind crazy one day to return to normalcy in a matter of a week or two weeks when properly medicated. And yet that same person, who very often will stop taking his drugs when the civil libertarians get involved, will be a homeless, deranged mess in another few weeks, off his meds.
I know that you have said you are dropping out Rich. But I truly feel that I have to respond. At least one of the folks you mention (and I will invoke confidentiality) has had essentially the experience you have had and has arrived at very different conclusions.
This truly illustrates how important it is to not project our own feelings and reactions onto others and to assume that they would feel the same way that we feel.
It’s too bad that Rich’s family member (and Rich) is suffering due to a severe mental illness. I wish both him and Rich well in getting (and staying) in treatment.
My final note would be to wish that Rich did not assume that there are not others responding to these posts who don’t have family members with severe mental health problems. Those of us who have troubled family members can see their suffering and still believe differently than Rich does. To suggest that I “would be singing different tune” is simply to deny the different experiences we all have.
David, is it possible that you also didn’t have an opportunity to really read Rich’s 12:30-ish responses here before you wrote your 2:44 p.m. comments (as I didn’t before I wrote) or his comments on the Enterprise site (which I did read first)? I guess that’s just wishful thinking on my part since you somehow were able to claim, in effect:
1.) “i know you did not say what I said you said, but it’s okay for me to misrepresent and claim that you did.”
2.) “I know you replied that you didn’t say what I said you said–and you said that what I said you said you said is not what you meant, quite the contrary–but it’s okay for me to then say you really meant what I say even if it’s contrary to you clear denials.”
3.) “If, after using this misrepresentation technique three times on three serious points, it’s fine for me to toss in
the ol’ Slippery Slope argument, only to discredit you without any explanation about how we could get to the ‘world of problems’ I foresee.”
I think it’s very clear to the casual observer that Rich did not say or mean what you’re claiming even after he corrects the record for you. It’s as though you’re more interested in avoiding responsibility for your own words than in acknowledging what might be misinterpretations and moving along the discussion.
Awhile back you asked me what examples I could point out as personal attacks. How you handled this story is somewhat illustrative. Rich “demonstrates a lack of common sense” in his column and you expected a lengthy response but not his “doctoral dissertation” in which “it becomes clear (he) has no interest in protecting Mr. Loughner at all,” and “admits he doesn’t give a damn about the well-being of Mr. Loughner” and he’s the last person who out to be making this decision.”
As I said before, we might differ on defining personal attacks in this arena. And setting aside the fact that several of these start out as lies before you turn them into attacks on his intelligence and/or morality, not one of the personal comments helps support your view on the matters you brought up for discussion. I call it “the Dunningization of Davis debate” and your techniques don’t advance the causes you support.,
If prosecutors charge that you wrote “I want to kill Bill” in the face the paper that actually states “I want to pay my bills,” would the judge accept the prosecution retort this is just “your rhetorical device.” (“Even though you didn’t explicitly state that you wanted to kill Bill (quite to the contrary), I’m here to tell you that you didn’t mean what you wrote. Moreover, in spite of your protestations, I know what you really meant.”
Wouldn’t it be easier to accept that what we say is what we mean here, particularly after we’ve corrected your mischaracterizations about our writing. That way you wouldn’t have to keep saying things like ‘you have taken the wrong point of entry” or “you’ve missed the point” or “you can argue that you never explicitly said that but….”
I’d much rather learn something here (not an unusual happening) than to see the tit-for-tat take over the issues.
Rich –
I would normally not respond–but you did single me out by name in your farewell comment. I cannot fathom how you can be so presumptuous as to assume you are the only person participating in a discussion (or, if you insist, argument) who may have personal experience or a close friend or relative with serious mental health issues. How could you possibly know that?
Nor can I not respond to your suggestion that anyone with your experience would agree with you. The mental health rights advocacy movement is largely client-driven. Many of the most outspoken mental health civil rights advocates are themselves self-described “psychiatric survivors” who have personal experience with involuntary treatment. Many still struggle with mental health issues. The issues are complex and controversial. But it does not further the discussion to dismiss other perspectives by engaging in attempted one-upmanship.
Please use the following as replacements where they seem appropriate:
?
ought
“
“
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David/Don: Any way for me to submit the problems I’m having on the site? I’ll check in with Apple, but this is the only place where it’s such a struggle with the operating system.
A thank you to Elaine Musser for letting people know that Eleanor Roosevelt Circle provided this person a home. Neighborhood Partners is proud to have developed ERC againt numerous hurdles put up by City staff.
ERC is the only affordable senior housing in Davis with an on site supportive services coordinator.
David Thompson
Neighborhood Partners, LLC.
Rich: That’s pretty presumptuous on your part to believe that you are the only one here with such an individual who is either a friend or a family member. In fact, I would guess everyone here has a friend or family in the exact situation you describe.
JustSaying:
I’m not exactly sure what problems you have, but if you send something to me at info@davisvanguard.org, I’ll be sure to pass it along to the computer folks.
Eric Gelber mentions outreach and other outpatient services that, according to studies, can result in mentally ill people complying with treatment (i.e., meds) without being institutionalized. The problem is that, for the most part, such services did not exist in most areas even before the budget cuts of the past few years.
Philosophically, I agree with everything Eric says. But this is the real world and, in practice, it would be in everyone’s interest (the mentally ill individual and society) if people with serious mental illnesses could lawfully be required to take their medication. I base this opinion on my experience working as a nurse in an inpatient psychiatric facility, representing the mentally ill in litigation against public entities and, like others, having a relative who suffers from a serious mental illness.
My brother was diagnosed as a paranoid schizophrenic 35 years ago and has been seriously mentally disabled at all times since then. He has spent most of those years going through the revolving door in & out of the criminal justice/mental health system: He goes off his meds, becomes delusional, ends up in legal trouble, gets sent to a state hospital or criminal evaluation facility because he is not competent to stand trial, gets some psychiatric treatment and gets restabilized on meds, is released when the charges are dropped after about 2 years, and then the cycle starts again. What a waste of a life, and what an inefficient system!
I just want to say that I always learn a lot from threads on this topic, and thank the participants who have knowledge, expertise, and opinions in this field for participating. I have a feeling that Eric, rdcanning, and Rich could, if they could set aside their differences, find areas of agreement and could probably devise strategies for policymakers that would be better than the status quo. Current policies seem reactive, and there are very undesirable results from previous legislation and court decisions.
Thanks again.
To everyone: I worked on the MHS Prop 63 committee that devised the Older Adult Program, the mobile assessment team that went out to frail elder’s homes, to make sure they were okay, were taking their meds, etc. Since the budget crisis, the Older Adult Program as it was envisioned and operating, is no more. MHS is operating on a shoe string, and can only serve those who are severely mentally ill. My client that I spoke of probably would not even register on the MHS radar screen (and I say this non-critically and with some degree of certainty (cannot legally provide specific details)). MHS us crumbling, so we are operating in a very un-idealistic world. Thus I respect all points of view here, despite the extreme divergence of views. There are no easy answers, that is one thing for certain…
I have been reluctant to comment because of confidentiality issues, but there is a lot of mis-information being put forth that should be corrected. First, there are legal ways to enforce medication, if necessary. I have a family member who is equally as ill as Rich’s relative, but she is being treated by the County under conservatorship rules.
A person who is conserved has been deemed by a court as gravely disabled, and gives up a number of rights, and is overseen by the County Public Guardian. Cass Sylvia is Yolo County’s Public Guardian, and in spite of being severely underfunded, does a wonderful job of looking out for these unfortunate members of our society.
Once a person is conserved, treatment can be mandatory, and in our case, has been, with positive results. I don’t know where Rich’s relative lives, but it would seem that this would be a possible solution to his dilemma, should the people involved wish to pursue this solution. In our case, at least, it was a last resort.
Finally, my personal observation about the frequency of mental illness has been that every time I have mentioned our travails to someone, they have brought up a similar situation in their own family or extended family. Rich is dead wrong in thinking that he is unique.
To Yolo Mind: Thanks for sharing…