Friday, January 21, 2011

Crazy nation.

In the wake of Jared Loughner's shooting spree in Arizona, there's been a deluge of articles and commentary and cable-news handwringing about the state of America's mental health care system.

Hahahaha. In answer, you may ask, what mental health care system? The same questions came up after the Virginia Tech rampage, and the one before that, and the one before that - but for Virginia specifically, the same problems that plague what shreds of a mental health system that can be said to exist are the same problems that plague the rest of the country.

For answers to the question why someone so apparently unbalanced can't be committed you have to go back...way back, to the 1970s and the end of the civil rights movement, when the philosophical foundations of how America could treat the mentally unwell were fundamentally changed.

Pete Earley, a former reporter for the Washington Post, nonfiction author of several works that touch on criminal justice in America, and novelist, does that and more in Crazy. Earley began work on Crazy after his son Mike was arrested in Fairfax County after suffering a psychotic break. Mike, who had no prior history of drug use or erratic behavior, or any family history of mental illness, was eventually diagnosed with schizophrenia. As Earley strugged to navigate the unfamiliar world of mental illness, he leveraged his knowledge on criminal justice and skills as a reporter to begin his own investigation.

What he found should be shocking, should spur reform, should do this and should do that. Realistically, it's not going to, and Earley himself points out why.

Earley starts out with his own story. His college-age son, Mike, had begun acting erratically while attending school out of state, which Mike blamed on the stress of college and overwork. After getting alarmed enough about his behavior to bring Mike back home, Mike ended up suffering a psychotic break and broke into an empty house in suburban Fairfax, where he was arrested by deputies responding to the alarm. Although Earley thought that he could get help for Mike after he was arrested, he soon learned that because of the interpretation of current mental health treatment laws - laws developed in 1970 - there was no way that Mike could be involuntarily committed or treated with medication until he harmed himself or someone else. Meanwhile, Mike was facing two felony charges.

After beginning the labyrinthine legal process to both try Mike and try to get him help, and running into obstacle after obstacle, Earley went to Miami-Dade County, Florida, to try to figure out why getting his son help was so hard.

Why Miami-Dade? Well, not only is the name Miami-Dade synonymous with government incompetence, Miami-Dade has an astronomically high rate of mental illness and homelessness. After Kennedy told Cuba that Cubans fleeing Communism would be welcomed with open arms, Castro took the opportunity to empty Cuba's mental asylums and jails and send 'em on over, where many stayed. Consequently, Miami-Dade's already dysfunctional mental health system was overwhelmed.

Then the 1970s hit, and things got worse. Thorazine had been on the market for a few years, touted as a wonder drug for treating a wide range of seemingly intractable mental disorders. And Thorazine did work for many patients, but for others, it turned them into zombies. Overmedicating became routine, and a growing backlash against medicating patients involuntarily, coupled with a shift in the philosophy surrounding civil rights and high-profile lawsuits triggered on behalf of institutionalized patients resulted in the passage of several laws that fundamentally changed how mental health could be treated.

This was the genesis of the "harm to self or others law" that effectively ties the hands of anyone seeking treatment on behalf of a mentally ill person. The problem is rather obvious, as "harm to self and others" is a very vague definition of who can be involuntarily treated. And furthermore, Earley argues that treating a mentally ill person involuntarily is a Catch-22, as most mentally ill people need treatment first in order to be rational enough to decide whether to continue receiving medication. But by wording the law this way, America was able to empty and shutter its state-run treatment facilities and effectively wash its collective hands of treating the mentally ill by claiming that patients could only be voluntarily committed and treated except under the most stringent guidelines. As a result, only patients who had already harmed themselves or someone else could receive treatment, at which point they were much more likely to be jailed instead of hospitalized.

The end result is the warehousing of the mentally ill in jails, without effective treatment and most often in horrendous conditions, without any hope of recovering or receiving adequate medical care. There's simply no other place to put them.

In Florida, Earley met with both the mentally ill and those trying to help them, including the overburdened psychiatrists and nurses in Miami-Dade's penal system who struggle against overwhelming odds. Earley visited the notorious ninth floor of the Miami-Dade Country Pretrial Detention Center and records the medieval conditions, overcrowding, and brutal treatment by the prison guards. The purpose of the Pretrial Detention Center is to make prisoners competent enough to stand trial, although as Earley would find out, some prisoners spent years shuttling between detention centers and the courtroom as their condition continued to deteriorate. As Earley points out, the result of the closing of facilities and the termination of treatment options has led us back to the inhumane conditions of early mental instutitions, an especially cruel irony given that many of the lawsuits that forced the closing of those institutions were made under the auspices of protecting the mentally ill. The end result did close institutions that were subpar, but no alternatives were made available, and the vast majority of those institutionalized ended up homeless and later, incarcerated.

Which brings us back to Arizona, which is facing a massive budget shortfall that has put mental health programs on the chopping block. Ironically, Governor Jan Brewer's son is schizophrenic and has been institutionalized for over two decades after being ruled incompetent to stand trial for kidnapping and assault, and Brewer has made efforts to protect Arizona's mental health programs.

However, as Earley explains, simply upping the federal funding or number of programs doesn't help when the law effectively ties the hands of anyone trying to find treatment for a mentally unwell person. Earley makes a compelling argument against the current legal framework, particularly given that most of the laws regulating how and when a person can be compelled to enter treatment were written before much of what we now know about disorders like schizophrenia were discovered.

Crazy doesn't have a happy ending. Although Earley does find some bright spots in the work of the dedicated individuals who provide treatment, it's clear that the 'mental health care system,' such as it is, is not going to get fixed any time soon. At the end of the book, Earley's son Mike has improved and is living a relatively independent life - but as Earley knows, Mike will spend the rest of his life fighting his disease.

The next time someone asks why you can't just lock 'em up, give them a copy of Earley's book. Crazy does a thorough and quick job of explaining why America's "mental health care system" is more hallucination than reality.

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