American Samizdat

Friday, April 27, 2007. *
An essential measure of a civilized society is in how it treats its sick. When it comes to public policy and practice, the US is decidedly uncivilized and is descending to outright cannibalism. Witness, for example:
Protect the mentally ill

Cara H. Drinan/Special to The National Law Journal
April 16, 2007

On April 18, the U.S. Supreme Court will hear arguments on the question of whether Texas may execute Scott Louis Panetti, a man who believes the state is punishing him for preaching the Gospel. In reality, of course, the state is punishing Panetti for committing murder, but the state's genuine reason is beside the point to Panetti, who was first diagnosed with schizophrenia in 1986 and was hospitalized more than a dozen times before he was arrested for murder in 1992. Panetti v. Quarterman, No. 06-6407.

In 1995, while on trial for his life, he represented himself — wearing a cowboy costume. Instead of asking the panel of potential jurors a question, Panetti said: "The death penalty doesn't scare me, sure but not much. Be killed, power line, when I was a kid. I've got my Injun beliefs as a shaman. I sent the buffalo horn to my sister. Adjustment, Jesus wrote." His standby counsel described Mr. Panetti's appearance at trial as "a joke ... like out of a dime store novel."

Panetti's case demonstrates that, for the severely mentally ill, the purported rationales for capital punishment — retribution and deterrence — ring hollow. Because Panetti believes that he is a victim of a government conspiracy, he certainly cannot "prepare himself for his passing," as Justice Lewis F. Powell articulated in the 1986 case of Ford v. Wainwright, in which the court held that the Eighth Amendment bars the execution of the insane. Moreover, Panetti's execution will not effectively deter others like him who commit acts of violence in a haze of hallucination, delusion and paranoia.

A recent U.S. Department of Justice study reports that 56% of state prisoners and 45% of federal prisoners have a mental health problem. The study also reveals that mental health problems are strongly associated with violent crimes and recidivism: 61% of state prisoners who have a mental health problem also have a present or past violent offense. These numbers suggest two conclusions: Untreated mental illness can lead to violent crime, and untreated mentally ill prisoners commit crimes repeatedly. At the same time, many mentally ill individuals cannot receive the health care they urgently need. The National Alliance on Mental Illness has reviewed and graded every U.S. state and its mental health care system, and the national average is a "D." Panetti's home state of Texas ranks 47th in the nation for per capita mental health expenditures . . .

According to the 5th U.S. Circuit Court of Appeals' application of Ford, Panetti does not meet the definition of insanity required to avoid execution. However, in the more than 20 years since the Ford opinion, the appellate court has yet to find a single inmate incompetent to execute. Even those who subscribe to the strictest method of constitutional interpretation should reject the execution of Panetti and those who are similarly insane, for even English common law recognized that execution of the insane "serves no purpose ... because madness is its own punishment." The court should rule for Panetti and confirm that the Eighth Amendment bars the death penalty in cases where the defendant has no rational understanding of the state's reason for punishing him.
Panetti is not, of course, an isolated case. The National Alliance on Mental Illness (NAMI) reports, in "The Criminalization of People with Mental Illness" . . .
In 1992, NAMI and Public Citizen’s Health Research Group released a report, entitled Criminalizing the Seriously Mentally Ill: The Abuse of Jails as Mental Hospitals, which revealed alarmingly high numbers of people with schizophrenia, bipolar disorder, and other severe mental illnesses incarcerated in jails across the country. Most of these people had not committed major crimes, but either had been charged with misdemeanors or minor felonies directly related to the symptoms of their untreated mental illnesses, or had been charged with no crimes at all. Unfortunately, the problems described in that report have worsened in the ensuing years.

A report issued by the United States Department of Justice in 1999 revealed that 16 percent of all inmates in state and federal jails and prisons have schizophrenia, manic depressive illness (bipolar disorder), major depression, or another severe mental illness. This means that on any given day, there are roughly 283,000 persons with severe mental illnesses incarcerated in federal and state jails and prisons. In contrast, there are approximately 70,000 persons with severe mental illnesses in public psychiatric hospitals, and 30 percent of them are forensic patients. Additionally, police are increasingly becoming front-line respondents to people with severe mental illnesses experiencing crises in the community.

Conditions in jails and prisons are often terrifying for people with severe mental illnesses. These settings are not conducive to effectively treating people with these brain disorders. Many correctional facilities do not have qualified mental health professionals on staff to recognize and respond to the needs of inmates experiencing severe psychiatric symptoms. Correctional facilities frequently respond to psychotic inmates by punishing them or placing them in physical restraints or administrative segregation (isolation), responses that may exacerbate rather than alleviate their symptoms. Inmates with severe mental illnesses usually do not have access to newer, state-of-the-art, atypical antipsychotic drugs because of the costs of these medications. Federal and state prisons generally do not have adequate rehabilitative services available for inmates with severe mental illnesses to aid them in their transition back into communities.

These alarming trends are directly related to the inadequacies of community mental health systems and services. The widespread adoption of systems with proven effectiveness in addressing the needs of people with the most severe mental illnesses, such as assertive community treatment programs, would sharply decrease the numbers of people with severe mental illnesses involved in criminal justice systems. However, since these programs are available only sporadically throughout the country, NAMI’s strategies for reducing criminalization focuses both on improving community mental health services and on addressing the treatment and support needs of people with severe mental illnesses in criminal justice systems . . .
Amnesty International USA, in launching a campaign to protect mentally ill "offenders" from capital punishment, states . . .
There are currently around 3,400 people on death row in the USA. It is not known how many of them suffer from mental illness or other impairments of the sort listed above. The National Association of Mental Health has estimated that five to 10 per cent of the US death row population have serious mental illness. This would be consistent, for example, with a recent study which investigated 2,005 people convicted of homicide in Sweden over a 14-year period. The researchers believe that it is the largest study to date of mental disorders in homicide offenders. It found that one in five suffered from a psychotic illness. Specifically, 8.9 per cent of the individuals had been diagnosed with schizophrenia, 2.5 per cent with bipolar disorder, and 6.5 per cent with other psychotic disorders. The study pointed out that the homicide rate in Sweden was about three times lower than in the USA and suggested that "in countries with more liberal gun laws, the proportion of mentally disordered homicide offenders may be different". The study pointed out that earlier research in the United Kingdom and Finland had each found that six per cent of homicide offenders suffered from schizophrenia.

In any event, the primary purpose of Amnesty International's report is to illustrate that people with serious mental illness continue to be sentenced to death and executed in the United States of America, that existing safeguards are clearly inadequate to prevent this from happening, and that there is a profound inconsistency in exempting people with mental retardation from the death penalty while those with serious mental illness remain exposed to it . . .
In the same report, AI lists in detail 100 executions of mentally ill people in the US since 1977. The list is tragic, the practice unconscionable.

Executions are the ultimate, but not the only consequences for "crazy" people. Perhaps the most famous recent case is that of Andrea Yates, a woman suffering from schizophrenia and severe post-partum depression when she drowned her five children in her bathtub in 2002. Instead of being remanded to treatment, she was sentenced to life imprisonment. Texas. Shame.

In the late 19th century, the concept of "asylum" was born. Prior to that, the mentally ill were vilified, feared, and subjected to horrible treatment and conditions. Dorothea Dix, among others, advocated and built institutions which were designed to protect mentally ill people from society, not the other way around. It was a question of enlightenment and humanity.

What are known now as "state hospitals" were usually large, complex community campuses with many buildings, including cottages which housed both patients and staff. In many cases, such as Dorothea Dix Hospital in Raleigh, NC, the campuses included expansive park areas, well-kept and even bucolic.

The intentions were excellent. The pace of medicine and public enlightenment and commitment have been much less than consistent, however. Popular prejudices remain essentially undented by the findings that mental illnesses are brain disorders, chemical imbalances which produce sometimes radical malfunctions of thought and emotion. And it is truly only in the last ten or twenty years that medications have been developed which ameliorate symptoms without producing debilitating side effects.

It was not long before these original asylums became little more than warehouses. Sadly underfunded for adequately treating the increasing populations of mentally ill humans, and lacking the medical resources to effectively treat them, state hospitals became soon overcrowded and understaffed. Available medications were used not so much to make patients more comfortable, but more "manageable." I can tell you from first-hand experience what 500 megatons of Thorazine will do to your attitude and behavior. You're not going to bother the staff very much, believe me. (Oh, could I tell you stories!)

With underfunding, of course, quality of care plummeted quickly. Reductions in medical professionals (doctors, psychologists) shifted the burden to nurses, then further to "technician" staff (what we used to call "aides"). Techs, although many are truly committed to this helping work, are overburdened and in many cases are little more than guards. When I worked as a trainer for a Massachusetts state hospital in the 70s, 80% of our aides were Haitian immigrants, whose culture holds that the mentally ill are possessed by spirits and demons. You can imagine some of the interactions between aides and patients, but the work is not glamorous and we hired whoever we could get.

To emphasize my point, this is from "Mental illness history comes full circle: 161 years after Dorothea Dix pulled mentally ill out of U.S. jails, they are back again", a 2002 article in The Macon Telegraph:
In 1841, a Boston schoolteacher named Dorothea Dix set out for the local jail to teach a Sunday School class. What she discovered there changed history.

Dix was horrified to find mentally disabled people crammed into unheated, unsanitary quarters with all kinds of criminals.

Her revulsion and crusading spirit ignited a social movement that spurred the creation of "asylums" - places of refuge - all over the nation for people with mental disorders.

The asylums themselves ultimately became scandalously overcrowded, abusive and in need of reform. And in the late 20th century, the mental hospitals emptied out. But in their place, jails have once again become the institutional answer to mental illness.

"We've sort of gone back to the Dorothea Dix days," says Richard Elliott, a psychiatrist at the Mercer University School of Medicine.

A few decades ago, most people with chronic mental illness wouldn't have been on the streets or in jail. They would have been locked in state psychiatric hospitals like Central State in Milledgeville.

What happened in the interim is commonly described with a four-dollar word: Deinstitutionalization. It means taking people out of the institution . . .

"We deinstitutionalized people with the best of intentions," says Dr. E. Fuller Torrey, a leading national advocate for mentally ill people and their families. "Basically we opened the doors and waved goodbye and said, 'If you'd like to get some treatment that's fine. We'll be glad to provide it, but that's up to you.'"

In most places, however, adequate community services never materialized to follow up on the released patients.

Torrey says the result was a huge upsurge in the number of homeless, hallucinating, hurting people wandering the streets, either unable to find treatment or refusing to seek it.

"One predictable consequence is that an increasing number of these discharged patients ended up in jail," Torrey wrote in a 1998 study. "The three largest de facto psychiatric inpatient facilities in the United States are now the Los Angeles County jail, the Rikers Island jail in New York City and Cook County jail in Chicago."

Another trouble, Torrey says, is that when deinstitutionalization began, mental health professionals and policymakers did not yet understand something important about the way mental illnesses affect the brain. Through technology such as magnetic resonance imaging, neuroscientists now understand that the brains of people with schizophrenia and manic depressive illness are different. The diseases impair a section of the brain governing insight.

"They have damage to the parts of the brain that we use to think about ourselves," Torrey says. "So almost half of people with this illness are sitting out there saying, 'Look, there's nothing wrong with me.' As I've been told 100 times if I've been told once, 'Doc, if you'll just stop the CIA from sending those messages to me, I'll be fine. But I don't want your damn medicine, and I don't need it. There's nothing wrong with me.'" . . .

Elliott says deinstitutionalization may not be the best term for what has happened. He calls it "trans-institutionalization."

"Nobody was really deinstitutionalized," he says. "They were trans-institutionalized to other institutions, like nursing homes or jails."
Institutions, of course, ill-equipped and unmotivated to provide the compassionate treatment required.

I mentioned above that emerging pharmacology shows promise, if not yet for a "cure", then of more effective treatments without troubling side effects. Therefore, whereas older medications have been largely used for patient management, producing a significant risk that a patient will stop taking them because of the extreme discomfort, newer medications seem to actually heal the brain without the side effects. I, for example, would never think of abandoning my bi-polar medications - because they work and, thank god, I am side-effect free.

Much of the problem here is economic, not clinical. Mentally ill people are less likely to be "productive members of society" than so-called "healthy" people. Social Darwinism is very much alive in the US. The finest, latest medicines and treatments are available only to folks with money. Why, we think, should we pour bucks into caring for people who are never going to be capable of contributing significantly in the workplace? It's cheaper to warehouse people than effectively treat them.

Mental Health America, an advocacy organization, in 2002 noted:
During September NMHA is sending to Congress a series of appropriations “fact sheets” aimed at raising awareness of mental health issues and the need for an increased federal commitment to mental health funding. NMHA hopes the materials will lay the groundwork for Congress to allocate the needed resources not only to provide treatment for mental disorders for the millions unable to access these services, but to make prevention of mental illness and promotion of mental health important public health objectives.

Congress will soon begin consideration of the FY2002 Labor, Health and Human Services Appropriations bill. Funding for mental health programs is in jeopardy; the Administration has proposed a cut for mental health services in its FY2002 budget . . .

Research Shows that Not Investing in Mental Health is Expensive

* According to the Global Burden of Disease Study, the impact of mental illness on overall health and productivity is profoundly under-recognized. Today, in market economies such as the United States, mental illness is the second leading cause of disability and premature mortality.

* The total yearly cost for mental illness in both the private and public sector in the U.S. is $205 billion. Only $92 billion comes from direct treatment costs, with $105 billion due to lost productivity and $8 billion resulting from crime and welfare costs. The allocation for the cost of untreated and mistreated mental illness to American businesses, the government and families has grown to $113 billion annually.

* Employees who are depressed are twice as likely to take time off for health reasons than employees who are not depressed, and are seven times more likely to be less productive on the job. However, the success rate for treating clinical depression is approximately 80 percent.

* Treating people in communities is far less expensive than treating them in institutions. In one recent study, total treatment costs in the community, including the cost of housing, was $60,000 per person per year compared to $130,000 for institutional care . . .

Without Mental Health Services, Society Pays a Larger Bill

* Twenty percent of youths in juvenile justice facilities have a serious emotional disturbance and most have a diagnosable mental disorder. Up to an additional 30 percent of youths in these facilities have substance abuse disorders or co-occurring mental health and substance abuse disorders.

* The unemployment rate among American adults with depression is 23 percent, compared to 6 percent of the general population.

* On any given night, over 600,000 people are homeless in the U.S., one-third of which has a serious mental illness.

* The World Health Organization estimates that depression and substance abuse are associated with more than 90 percent of all cases of suicide . . .

Research Shows that Mental Health is Under Funded

* In 1997, mental health and substance abuse expenditures represented only 7.8 percent of the more than $1 trillion of all U.S. healthcare expenditures. This is a decrease from 8.8 percent in 1987.

* The overall real purchasing power for state mental health appropriations between 1955 and 1997 declined from $16.5 billion to $ 11.5 billion.

* Mental illness is the second leading cause of disability in the U.S., yet only 7 percent of all healthcare expenditures are designated for mental health disorders . . .
This was in 2002. The situation has gotten worse, not better. Adequate community treatment is rare, to a great degree a function of privatization. The hope that competition would stimulate effectiveness is a pipe dream; striving for lower costs only results in lower standards of care and misery.

Perhaps there is some hope, but not from the feds. This month, in "[Iowa's] House OKs increase in mental-health funding", The Quad Cities Times reported . . .
The Iowa House on Friday approved $13.3 million to help counties provide care to people with mental-health conditions or developmental disabilities, under a measure pushed by Rep. Elesha Gayman, D-Davenport.

Many counties have faced a perennial problem of finding enough money, and Scott County officials announced earlier this year they would cut services because of budget shortfalls.

Gayman said the state assistance will help keep down property taxes Iowans pay. Her plan also called for study to see what other financial assistance the state could provide.

“I think it’s going to be an exciting opportunity to look at what we can fund at a state level and start moving to that direction rather than having a nightmare every year,” Gayman said . . .
More money, sad to say, is not the only crying need. A recent story from LA, "Caught On Tape: Caretakers Abuse Mentally Ill Men", is shocking, but not uncommon:
Los Angeles police have released shocking video taken on a cell phone.

It shows a caretaker physically abusing two mentally handicapped men.

The victim, described as a 38-year-old man with the mental capabilities of a 2-year-old, is hit repeatedly last April inside a bathroom at the Jossen Vocational Academy day program in Anaheim . . .

Also on the cell phone was another video, showing a second victim -- a 38-year-old man with the mental capabilities of a toddler.

The video shows him being hit numerous times while the suspects laugh . . .
Physical abuse is not the only affront the mentally ill must endure. As a society, we have also mentally, emotionally, and spiritually abused our fellow humans, just because they scare us or anger us or disgust us or amuse us. Is this not mass sick behavior?

In the state hospital in which I served the mentally ill a few decades ago, there was a young, brilliant psychiatrist. One of his responsibilities was facilitating therapy and discussion groups and education sessions for patients. I sat in on several and was amazed.

In the middle of one session, a patient asked the doctor, "Doc, do you ever hear voices, hallucinate, or laugh or cry uncontrollably?"

The psychiatrist replied, "Never." The young man asked, laughing, "What's wrong with you?"

What's wrong with us, indeed?

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