Trapped between law and madness

0 Comments | Insight on the News, Sept 14, 1998 | by Aimee Howd

It is a public-policy issue, but it cannot be decided apart from its social and humanitarian context. Roughly one-third of America's homeless are like Weston -- suffering from mental illnesses such as schizophrenia and manic depression. While the recent shootings have inflamed public perception, advocates of both the homeless and the mentally ill say neither group inherently is dangerous. Experts claim that only about 5 percent of the mentally ill exhibit violent behavior and then usually in cases in which treatment is rejected or not available. Those cases most often are among the homeless.

"They need so much in terms of connecting with the community" says Rutgers University professor Nancy Wolff, associate director of the Center for Research on the Organization and Financing of Care for the Severely Mentally Ill. Beyond a stable residence, such people need accountability and interaction. For this to occur, law-enforcement and mental-health officials must establish clear lines of communication.

As things stand now, police officers, charged with defending public health and safety, will pick up an offender and transport him to the hospital. The hospitals will cite civil-commitment laws that require evidence of being a danger to self or others, very narrowly defined. So law-enforcement officials find it easier to incarcerate than to commit.

"Our jails, whether we like it or not, are becoming our largest mental-health facilities," says Wolff. "D.C.'s [law enforcement] has an extraordinarily good mental-health-services program. Unfortunately, once they are released from the jail, they are without their medications"

The courts now occupy the border between medicine and law. Some mental-health courts are using a therapeutic rather than a punitive jurisprudence. They create "preconditional release arrangements" restoring defendants to the community on the condition that they receive treatment and stay on their medication.

It's a new mechanism, Wolff says, and still needs closer examination in terms of legal, clinical and social-welfare consequences. "We put the seriously mentally ill in the community because we believe they are full citizens, but we also need to expect them to live within the social norms and the laws of our system."

E. Fuller Torrey, president of the Treatment Advocacy Center in Arlington, Va., says that the same involuntarily enforced protective measures should apply to schizophrenics and manic depressives as to patients with Alzheimer's disease. "Why allow them to put themselves in very dangerous situations? We rationalize that as defending their civil liberties."

The laws are interpreted too narrowly, says Torrey, who believes intervention should be more common. It has come to the point, he says caustically, where `"dangerous to self' means committing suicide in front of your psychiatrists and `dangerous to others' means trying to kill your psychiatrist." Torrey says the untreated mentally ill commit 1,000 homicides every year that could be prevented if involuntary treatment and commitment were allowed.