(Nov. 12, 2013) New York’s late Senator Daniel Patrick Moynihan’s devotion to social justice was equaled by his disdain for political correctness.

With the recent publication of Dr. E. Fuller Torrey’s American Psychosis detailing the collapse of the American mental health system Sen. Moynihan’s indictment of the Community Mental Health Centers Act of 1963 bears revisiting.

Since the passage of the act, Moynihan told Congress 15 years ago, “we have emptied state mental hospitals, but we have not provided commensurate outpatient treatment. Increasingly, individuals with mental illnesses are left to fend for themselves on the streets, where they victimize others or, more frequently, are victimized themselves. Eventually, many wind up in prison, where the likelihood of treatment is nearly as remote.

“[T]he planners had bet on improving national mental health ’by improving the quality of general community life through expert knowledge, not merely by more effective treatment of the already ill.’

“The problem was: there is no such knowledge…. So as the federal government turned to other matters, the mental institutions continued to release patients, essentially to fend for themselves.… Soon, the homeless appeared. Only to be defined as victims of an insufficient supply of affordable housing. No argument, no amount of evidence has yet affected that fixed ideological view.”

Sen. Moynihan would be disappointed to know that in 2013, “that fixed ideological view” continues to hold sway, and far too many of the most vulnerable individuals with severe mental illness continue to fend for themselves – in the streets, behind bars, in emergency rooms.

Read what Dr. Torrey had to say about the 50th anniversary of the act of Congress that set the stage for this tragedy in “A Psychiatric Trick or Treat” on Oct. 31.

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(Nov. 11, 2013) As if it’s not bad enough to be suffering from a severe mental illness and behind bars in a jail or prison – once inside, things can get very very much worse.

In New York’s infamous Rikers Island, a new study obtained by the Associated Press reports that just over half the 800 inmates confined to isolation in the prison are mentally ill, including six inmates who have each served more than 1,000 days in solitary (“AP: Review faults NYC on solitary for mentally ill,” Nov. 6).

Overall, 40% of the prison’s 12,200 inmates have a mental health diagnosis, the study found, including about 4,000 with severe mental illness. Self-mutilations and suicide attempts were up 75% in the five years ending in 2012, the study found, and use of force by correction staff on inmates tripled.

Meanwhile, a Washington, DC, study reports that 40% of the inmates in the District’s jail likewise suffer from mental health conditions, and their mental health problems are linked to “a rash of suicides” in which 165 inmates have attempted to kill themselves in the jail in the last two years (“DC jail works to stem rash of suicides, but mental-health efforts could strain resources,” Nov. 10).

The DC study said a “culture” in which jail officers and health workers regard “most suicide attempts (as) efforts by inmates to get attention, such as a night in a hospital room with dinner and a television” is in part to blame for the epidemic.

The response to Rikers’ exploding population of mentally ill prisoners so far has been … to create more beds for solitary confinement: The city has increased isolation beds by 61.5% in the past six years, (“Rikers Island study reveals overuse of solitary on prisoners with serious mental illness," Nonprofit Quarterly, Nov. 11).

Down in DC, Mayor Vincent C. Gray has committed $600,000 to … “start retrofitting aging cells to remove welded towel bars and clothes hooks” so it’s not so easy for inmates to hang themselves.

It’s bad enough that the people with mental illness most at risk to become inmates end up behind bars because they don’t get treatment for a treatable disease.

It’s inconceivable that, once they have, the best New York and Washington can come up with is to confine still more in isolation or take down their towel bars.

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(Nov. 8, 2013) Every day I think of our family's story and the loss of my brother due to his lack of treatment for his mental illness.

I lost a brother who for over 40 years was like any other member of our family. He was a college graduate, business owner and father who enjoyed spending time with his family. He was a regular guy.

Until he wasn’t.

Ten years ago he started getting off track and began to say things I had never heard him utter before.  He was someone I had known my entire life and suddenly he started taking on a new persona. For over a year there were gradual changes and then a spiral out of control.

I am a nurse, and I had absolutely no idea what mental illness truly encompassed until we were faced with his ultimate diagnosis of bipolar disorder. For my brother it was terminal.

His last manic period began when he was in Costa Rica in the spring of 2012. Somehow we were able to get Brad hospitalized in Costa Rica. Even being in another country this was easier than at any time back in the states. 

Unfortunately, once he was deported back to the United States all medical care immediately ceased.  His illness became worse and his path took him to jail. This was not the first time jail became his only way of being locked up and kept from making more acts of poor judgment. 

He was in and out of jail and in and out of mental institutions where he was usually only kept for three days. The social workers never listened, meanwhile his symptoms and his behavior worsened. All the while we stood by helpless. 

I constantly discussed with my brother, what goes up, must come down. And with time, we all realized the further up, the further down.  He came down very fast and hard in the end. When he was discharged from the hospital, the doctors told him, “There is nothing more we can do for you here that you can’t do at home.”  But he can commit suicide at home. 

Faced with moving into a group home, my brother who had run his own business couldn't face the humiliation and he committed suicide the night before being placed. 

Do I think that laws need to be changed? For the severely mentally ill, for those loved ones that have lost the ability to make proper decisions, have had multiple hospitalizations with their illness, absolutely someone needs to be their advocate. 

For those of us who know the person best, who can be their ally, we are relegated to a back seat position and absolutely no ability to help during times of crisis. 

While my brother had lost many things along the path of his illness, treatment would have helped him regain some of his dignity. There could have been a place for him in society, rather than a burden to it. 

Untreated severe mental illness will never have a positive outcome, both for the stability of the illness, and ultimately for the life of the person suffering. 

Please, we need to change the laws. We need to change the perception of these illnesses.  Without this, there will continue to be stories like my brother's, and families like mine will continue to mourn their loss.

Denise Schmitt
Wisconsin

Schmitt's brother lived in Florida

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(Nov. 7, 2013) Interviews and reviews around Dr. E. Fuller Torrey’s new book, American Psychosis, just keep rolling in.

The book published by Oxford University Press details how the Community Mental Health Centers Act dismantled the treatment system for America’s most seriously mentally ill individuals and the disastrous results.

From recent reviews:

“This powerful polemic presents a compelling case for the reform of the mental illness treatment system. Torrey helpfully offers solutions, maintaining that successful care can come through community mental illness centers, not community mental health centers. In the end, his argument is convincing” – from Library Journal’s November 15 issue

“As Dr. Torrey makes clear, mental-health policy was a bipartisan failure. Dr. Torrey estimates that $140 billion is annually spent on ‘grossly inadequate and disjointed services,’ a sum that ‘should be more than sufficient to support excellent services if the money were used wisely.’” – Dr. Sally Satel in the Wall Street Journal  

“American Psychosis…is Dr. Torrey’s latest and perhaps best effort to explain how the mental illness system went wrong, why we have so many tragedies and more importantly, how to stop them.” – DJ Jaffe in the Huffington Post

From a recent interview:

“[T]hat’s what the book’s all about…it’s about the 50-year history of mistakes we’ve made and my feeling that, unless we understand how we got here, it’s going to be difficult to figure out how to get out of here.” – Dr. Torrey in an interview with Diane Rehm

Read an excerpt from American Psychosis.

Purchase a copy of the book here. All royalties from American Psychosis have been assigned to the Treatment Advocacy Center.

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(Nov. 6, 2013) Founding Treatment Advocacy Center board member Carla Jacobs is a veteran mental health activist who helped shaped the dialogue surrounding mental health public policies in California. She is also a family member with first-hand knowledge of the devastating effects of untreated mental illness.

On October 24, Los Angeles County recognized Carla’s enormous contributions to mental health in the Golden State by awarding her one of three 2013 Profiles of Hope, Outstanding Family & Community Advocate awards. Former Congressman Patrick Kennedy and actress Mariel Hemingway were co-recipients.  

Carla started her advocacy career in 1991 as an appointee to a Los Angeles County task force on the incarceration of people with mental illness. Since then she has been instrumental in promoting laws, policies and practices throughout California and the nation to improve recovery for people with mental illness and support their families.

 With support from many organizations and individuals, Carla has successfully directed advocacy and legislation campaigns to reduce homelessness and criminalization of people with mental illness by improving standards and practices in community care.

Carla says she is guided by a basic principle that access to treatment for mental disorders is a human right as well as an obligation of and a benefit to the society that provides it.

She has served as a founding steering committee member on both Lanterman, Petris, Short Act (LPS) Reform task forces and as a founding steering committee member of the California Treatment Advocacy Coalition. She is former executive director and current board member of Proxy Parent Foundation.

The Treatment Advocacy Center joins Los Angeles County is saluting Carla Jacobs. This award could not have gone to a more deserving – or effective -advocate.

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(Nov. 5, 2013) Opponents of court-ordered treatment often say an all-voluntary mental health system would work just fine. Totally voluntary? No provisions for involuntary treatment? Let’s think what such a system would look like.

Those seeking help for anxiety and depression would get it (as they should now). Those seeking treatment for learning disabilities, attention deficit disorder, sleep disturbances, interpersonal problems, relationship stress, and sexual dysfunction would get it (as they should now). Even those seeking help for auditory hallucinations, paranoia, manic episodes, OCD and eating disorders would get it (as they should now). That sounds good. This world of totally voluntary treatment may not be so bad.

But then there are the nearly 50% of people with schizophrenia and 40% of people with severe bipolar disorder who don’t realize that they are ill and therefore won’t be voluntarily seeking treatment. Some of them will barricade themselves in their homes and live in fear of their paranoid delusions, stop eating, cease all communication with family and the outside world, and spend their days scared and alone. Maybe some will commit  “crimes” in response to their auditory hallucinations and end up in jail. Then they can be put in solitary confinement and begin to self-injure in response to their auditory hallucinations. 

Some will become homeless and eat out of trash cans —so disorganized in their thought processes that they can’t get their basic needs met. Some will be dressed for the winter in shorts and shoes with holes in them—so busy responding to their voices that they don’t realize that their extremities are frostbitten. Some will perpetrate violence because they are convinced that others are evil or intending to hurt them.  All the while, they will be “free” to choose to seek treatment for a disorder that they don’t believe they have.

Those in mental health institutions who sit naked smearing themselves in their own feces will be “set free” to decide if they need to voluntarily seek treatment. Those who have pulled out their own eyes because of visual hallucinations and delusional thinking with religious content (“and if thine eye offend thee…”) will be on their own to live their lives free of all of those pesky health care workers. Those who haven’t slept in days and believe that their mothers are possessed by the devil will return home to decide when the time is right to seek help. Those who believe that they are already dead with internal organs rotting inside them will be “liberated” to seek treatment on their own. Of course they will, right?  

So, this world of completely voluntary mental health treatment . . . it sounds good for those who don’t have a severe mental illness; actually it sounds like the world we live in now. However, this world of completely voluntary mental health treatment doesn’t sound so nice for those who are too sick to realize that they need treatment.  It doesn’t sound so good for the most ill among us, the most severely mentally ill who do not even know that they are ill.

It looks like those folks will end up homeless, scared and alone, in jails, freezing on the street, blind, covered in waste, or dead. Does that sound like a better world? The world in which we recognize the human right to starve, freeze, live in fear, permanently injure one’s self and spend one’s life incarcerated . . . all because that person doesn’t even know that they are sick.   

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(Oct. 31, 2013) Two letters in this week’s Baltimore Sun are calling for better treatment options for people who don’t recognize they are sick – a category that includes about half of those suffering with the most severe mental illnesses.

“Imagine you have a 24-year-old daughter with schizophrenia, delusional, living on the street, eating out of garbage cans and hearing voices telling her not to trust you or anyone else,” writes Arlene Saks-Martin in a call for assisted outpatient treatment (AOT) in Maryland (“Helping Maryland's mentally ill,” Oct. 30).

“She denies wanting to hurt anyone or herself so for years you cannot get treatment for her. Although she is gravely disabled, police and doctors have told you she does not meet the ‘dangerousness’ standard for involuntary hospitalization. Her teeth are falling out, her body has sores and she is a victim of crime, even rape. Can you honestly tell me she knows or cares or can exercise her civil rights?”

Kathleen Branch, the mother of an adult child with mental illness who is all too familiar with the shortfalls in the Maryland treatment laws, also weighs in. “It is critical for lawmakers to know that many of us desperately want to get a loved one evaluated and potentially hospitalized before something worse happens, but the laws stand in our way,” she writes  (“Laws surrounding mental illness make it harder for victims to get treatment,” Oct. 30).

Even though Maryland is one of the more well-resourced mental health systems in the country, the system exists largely for those who recognize they are ill and can voluntarily seek services.

The state is one of only five that remain without a law providing for mandatory outpatient treatment, and it has a high threshold for providing mandatory treatment in a hospital. If the state were to modernize its civil commitment laws to provide for court-ordered outpatient treatment and lower its threshold for involuntary hospitalization, those who are too ill to recognize it would be more likely to receive services.

“It is up to society — you and me — to rescue those with anosognosia by assuring they get timely, extended treatment to enable recovery,” urges Saks.

We agree.

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(Oct. 30, 2013) I have a 33-year-old son suffering from schizophrenia who is currently homeless. He is too paranoid to stay in a rented room and too delusional regarding our intentions as his parents to remain at home. And despite his multiple hospitalizations there have never been any positive outcomes upon his discharge. Despite all our efforts with him (since he was 20) in multiple counties with different doctors, he has been unable to avail himself of current treatment resources. Like many, he suffers from anosognosia, rendering him incapable of knowing that he is ill. This devastating form of denial is the impact of the disease of schizophrenia on the brain.

The other day he called and asked if I would bring him his books. I did and brought him home with me. When we got home I discovered what I have heartbreakingly discovered many times before: his legs were full of sores from bug bites caused by sleeping in the grass; his face was seriously sunburned, having no protection from the elements; the bag he was carrying smelled of urine; and his clothes did not come clean even after two washings. I let him shower, fed him, and let him sleep—hoping he would be free of the terror of being accosted while he slept.

And then I sat down and cried. I’m still crying as I write this, for I know the outcome already. He will stay here a few days but no longer. I can say this with certainty because the pattern is a very old one. After just a few days of rest he will begin to pace and then he will begin to accuse us of things that make no sense to the actual behaviors we exhibit. Then he will start to yell frightening comments and he will leave, sometimes voluntarily, but sometimes only with a call to 911.

With over fifteen years of hospitalizations and outcomes leading to homelessness each time, I have learned the horrifying reality that the only role I seem able to play in his life is to give him some respite now and then.

The good news is that my son has a group of supporters that we have never met: men and women who have struggled with their own severe mental illness. They are the heroes I watch with hope in my heart for my son. They are the men and women fighting for those who cannot fight for themselves. These men and women have found recovery, restoring the best of themselves with the help of medications, group and community support, county resources, and the ability to choose their own best approach. Sometimes they fight “for” and sometimes they fight “against” mental health recovery changes, like certain laws or regulations they feel steal a person’s dignity or human rights. Their motto is “nothing about us without us.” I like it.

They are saying to those who change the laws “please consider the human rights of each individual before you finish printing that law, or protocol, or program.” We need their voice! Grounded in their own experience and strengths, they have insights I may not have.

But as a parent of man who has been homeless and suffering for 16 years, I too, like many other parents with similar stories, have insights and experiences that others simply may not have. I have watched this illness rob my son of all personal dignity, of all ability to gauge what is real.  On the continuum of illness, he has been robbed of his ability to choose a path that creates the life his supporters now have.

And so I remind each of us: we are all on the same team. Our stories, however different, have informed our advocacy. We are fighting for people like my son—not against his ability to choose, but for the platform created by interventions that will get him to the same playing level that you, his supporters, now stand on. It is our job as fellow human beings to fight for the right to have the right to choose recovery.

Sometimes mandatory compliance and intervention are the only things that will restore a person to sanity so that he or she is no longer wandering city streets with a sleeping bag and “dying with [his] rights on.” (E. Fuller Torrey).

Gloria Davidson, MS, LMFT
California

Davidson hopes that sharing her story might reinforce the desperate need for Laura’s Law, California’s assisted outpatient treatment program, in Alameda County

(Oct. 28, 2013) “A police dispatcher had sent Officer LaRosa to what seemed like a routine accident call. When he arrived, [Billy] Lane, 25 years old, was outside his wrecked SUV, bloodied, holding a butcher's knife and threatening passersby. Mr. Lane advanced relentlessly on the police officer, who shot him four times. Mr. Lane died on the spot (“Lives of Mentally Ill, Police Collide,” the Wall Street Journal, Oct. 22).”

“You go through the academy expecting Joe Bad Guy to bail out of a car and start shooting at us," Officer LaRosa told Wall Street Journal reporter Gary Fields. "They don't train us for Billy."

Encountering “Billy” and other people in the throes of psychosis is often what leads to deadly encounters between law enforcement and people with severe mental illness. Our report “Justifiable Homicides: What is the Role of Mental Illness?” found that untreated severe mental illness is an increasing factor in officer-involved homicides.

When the responsibility for seriously mentally ill persons is shifted away from the mental health system to law enforcement, many people get hurt. "No police officer does well with shooting someone, let alone someone with mental illness," Michael Biasotti, Treatment Advocacy Center board member, told the Journal. “That destroys a bunch of people at once.”

We couldn’t agree more. Until states improve and use their assisted outpatient treatment (AOT) laws to support at-risk individuals and communities use crisis intervention team (CIT) policing to train law enforcement to handle encounters with people in psychiatric crisis, officer-involved shootings will continue to increase.

Read this powerful piece in the Wall Street Journal about collisions between people with severe mental illness and law enforcement.

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(Oct. 25, 2013) In the wrap-up panel at this week’s inaugural Kennedy Forum in Boston, SAMSHA  Administrator Pam Hyde brought up a topic increasingly in the news: mental illness and violence.

“We are increasingly talking about mental health as a safety issue, not a health issue,” Hyde told the audience of mental health professionals, leaders and advocates. “When we talk about mass killings, we are talking about mental illness not being treated.”

Hyde said she found it concerning to see mental health framed primarily as a matter of safety rather than health.

There’s good reason for such concern.

An estimated 3.3 million people in the U.S. are estimated to have schizophrenia or severe bipolar disorder, and about half of them receive no treatment for these treatable diseases in any given year. Headline violence involving mental illness typically comes from a very small subset of this untreated population. Typically, these are at-risk individuals who were running red flags for violent action up the flagpoles of their lives long before they acted.

Rare though they are, mass killings and other public violence play an outsized role in how the public views mental illness. A 1999 study found that 61% of American adults believe an individual with schizophrenia is “very likely” or “somewhat likely” to do “something violent to others.”* And that was before the headlines from Virginia Tech, Tucson, Aurora, Navy Yard and so many more locations now linked to violence and mental illness.

There is a school of thought that the stigma that results from such events will go away if we just don’t talk about it. It won’t. No matter how small their numbers, at-risk individuals who are left to deteriorate without treatment do pose elevated safety issues to their communities, will act on their untreated symptoms and will shape public attitudes not just toward their own small population but toward everyone with a severe mental illness diagnosis.

See “Stigma: Violence by seriously mentally ill persons is its major cause” for more on this issue.

* Pescosolido BA, Monahan J, Link BG et al. The public’s view of the competence, dangerousness, and need for legal coercion of persons with mental health problems. American Journal of Public Health 1999;89:1339–1345.

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