Mental Health

Our minds define our place as members of the human race. The reality of a fractured mind is something we prefer not to contemplate or fund treatment for lest we acknowledge that such a thing exists and we could find ourselves sharing the problem.

No one wants to admit that a friend or family member is losing their mind. Denial is the normal first reaction. Eccentric behavior is excused with a shrug or an excuse. The person is tired, upset, nervous, or just having a bad day. For a time these explanations seem logical, but eventually reality sets in. Something is definitely wrong and the stigma of mental illness takes over.

The common words used to describe what is happening are frightening—crazy, loco, cracked, daft, looney, mad, insane. No one wants to apply those words to a loved one. The fear of what friends, neighbors and fellow workers will think takes over. Better to hide the knowledge from everyone and hope whatever is happening will go away of its own accord. But it doesn’t.

The delusions get worse, paranoia sets in, voices start, episodes of odd behavior get harder to ignore. The realization hits—this is a severe illness and medical help is needed.  However, all proof and logic to the contrary, the person refuses to believe they are ill and rejects treatment. They are exhibiting “anosognosia”or “lack of insight.” The disease has caused a frontal lobe dysfunction, and the person is unable to process reality, or logic, or proof about their behavior. They believe sincerely they are acting normally. They are not “sick.” Even though someone brought them home naked after observing them putting out cigarettes on a neighbor’s car; even though they claim there is a relative being held captive in an obviously empty closet; even though they feel bugs crawling all over their body. Reasoning does not help. Producing contrary evidence does not change their mind, or their behavior.

Consultation with a doctor elicits the information that there is little you can do without the person’s permission to treat them. If they can be proved to be a danger to themselves or to someone else they can be committed involuntarily to a facility for a 72 hour evaluation, but if they refuse treatment they are released. (After all they are not “sick.”) Sometimes the person accepts that they need medication, but stops taking it after their release—they are not “sick.” And the cycle repeats.

Predictably faced with this situation eventually family and friends stop trying to help and the person is at risk for homelessness or jail. Sometimes they become so delusional they think they need to punish someone or make a statement by killing someone. As we have seen all too frequently tragedy ensues.  Sometimes the disease is fatal—the person commits suicide or an encounter with law enforcement ends in their death.

Prior to the discovery in the 1950s that Thorozine relieves the symptoms of severe mental illness, the treatment for this illness was institutionalization. Thorozine was hailed as a miracle drug. Within 10 years the treatment changed to deinstitutionalization. Patients were deemed capable of living in their communities as long as they were medicated and supported with outpatient resources. Long term treatment facilities were closed, and by 1955 95% of the beds available to treat the mentally ill were gone.

Sixty years of experience however have shown these original assumptions were flawed. The medications worked, but they also created difficult side-effects that reduced the willingness of patients to take them. Anosognosia prevents many patients from realizing their need to take their medications. The outpatient support promised is often non-existent due to lack of budget and resources. The stigma of mental illness keeps people from seeking the help that is available. Many live on the streets without any treatment or help.

New thinking is desperately needed. One possible solution is Laura’s Law. This law allows the courts to mandate treatment before the person becomes a threat to themselves or the public. The treatment can be outpatient or an involuntary committal. Where the law has been implemented participants are less likely to become homeless or to become violent. Patients support the program and credit it with helping them to lead normal lives. For families trying to help, it can be a lifesaver.

The San Diego County Supervisors have recently authorized the implementation of Laura's Law in San Diego County.

Since 2012 when this article was written San Diego County implemented Laura's Law (2015) and is using it as part of its tool kit for dealing with seriously mentally ill patients

A basketball player fractured his leg spectacularly on national TV. He was immediately surrounded by coaches, his team, doctors, and other health care professionals. He received immediate hospital care and is now well on his way to recovery. That is what we expect when someone is injured and needs medical help. So it seems impossible that we routinely leave people with badly fractured minds to fend for themselves, but we do, every day.

As a result, our cities are full of homeless men and women who can no longer function. Often self-medicated on alcohol and drugs and tormented by voices and delusions as their only reality, they cannot hold a job or take care of their own basic needs. Prey to crime, injury, and hopelessness, they wander untreated and uncared for along the streets and beg on the corners. Since 1955, we have eliminated over 95 percent of the public hospital beds for the mentally ill. There is no place left to care for them except the jails.

As a result, our prisons are full of the mental ill.  Riker’s Island in New York and the Cooke County jail in Chicago are now the biggest mental treatment facilities in the world. Over 50 percent of their inmates suffer from some sort of mental illness and the guards, untrained in how to treat psychiatric illnesses, are their caregivers. Bedlam, pun intended, is the obvious result. Committing a crime is the only way these very ill people get any treatment at all.

Even worse, we watch horrified as a young man, untreated for his problems, turns a gun on his mother, and a room full of school children and teachers, another shoots up a theater full of movie goers, and yet another opens fire on a meet and greet held in a grocery store parking lot. We shed tears, construct memorials, form foundations, pray, pass gun control measures, and know that there will be another horrifying event all too soon.

Caregivers face a person who often denies there is something wrong—lack of insight into the disease is a primary symptom of mental illness. In many states the only way a person can be treated who refuses treatment (and many do) is if they are deemed a danger to themselves or others. If the person refuses treatment after 72 hours, they are released no matter how ill or dangerous. Parents, siblings, and friends often simply give up trying to help, watching helplessly while their loved one joins the homeless, ends up in jail for a petty offense, kills someone while in the grip of a delusion, or commits suicide.

Surely we can do better than this. We need to change our approach to those with mental illness. We need to try to prevent violence not require it for treatment. Caregivers need tools such as California’s Laura’s Law and New York’s Kendra’s Law. These laws allow the courts to authorize assisted outpatient treatment and inpatient commitment before someone becomes dangerous to themselves or others. Laura’s Law also allows forced administration of anti-psychotic drugs. Studies show that where the laws have been implemented, the participants are far less likely to become homeless or violent. They are also less likely to be arrested. Overwhelmingly, according to the studies, those who have been part of these programs support them and credit them with helping them regain control of their lives. The laws include many safeguards for participant’s safety and their civil rights.

These laws work, and they have been passed in 44 states, but unfortunately they are often not available because implementation is voluntary and left up to the individual counties. California passed Laura’s law in 2002, but it has only been fully implemented in one county (Nevada County where it is very successful) and as a pilot program in Los Angeles.

To their credit the San Diego County Supervisors recently commissioned a 90-day staff review of Laura’s Law to determine if it should be implemented in San Diego. Costs and privacy issues will be considered as well as how to integrate the law into the current mental health programs.

We need to implement this law. We owe it to those who can no longer rescue themselves from their own fractured minds.