As a late adolescent, there was something in the world I lived in that was wrong in an absolute sense. Once that dawned on me, I never had a moment of doubt – the segregation of races in the South where I lived was wrong. In those times, that was not an easy realization, but there was a comfort in knowing something without reservation. My closest friends to this day are others who had that same awareness early on and involved themselves in doing something about it. But that may have been the last time I was ever completely sure about anything.
When I came to psychiatry from internal medicine, my first rotation was an acute service at an urban charity hospital – the emergency receiving facility for in-town Atlanta. It was at the wrong end of the deinstitutionalization process when all of the outpatient resources left over from the Community Mental Health initiative were disappearing along with the evaporation of inpatient beds. It seemed as if the patients that I thought needed to be in the hospital didn’t want to be there; and the patients that I thought didn’t need hospitalization were lobbying to get admitted. The same thing was true of medications. It felt as if I was always positioned against the flow, and I was never "sure" about anything.
One thing I learned in those days was to listen to people who had been there in person. An apt analogy would be the difference between civilians and veterans. There is an intrinsic impossibility in psychotic illnesses felt by both the afflicted and their caretakers that is a required ingredient in any cogent discussion of the topic. In my case, later I ran that same service for a year or so and then spent a decade directing the training program that staffed it and several others like it. The most important part of both jobs was helping the residents learn to make sensible decisions based on the individual patient in front of them, rather than becoming polarized in the confusion of chronic impossibility. I had seen that happen to two fellow residents [in different directions], both with disastrous results.
I have nothing but respect for those who stayed in public psychiatry where most psychotic mental illness is treated. It’s a very hard road. But even those with these more informed opinions vary widely when it comes to the inevitable conflict between patients’ rights and the need for treatment and/or restraint. In fact, it’s almost impossible to find any discussion that doesn’t turn the problem of psychosis towards one or the other of these priorities, often implying that the other party is ignoring the more important side of the equation. And that’s not meant as an indictment – it’s just in the nature of the problem as I see it. An observation: among people in the business, independent of what they might say in an armchair discussion, they are usually indistinguishable in how they approach a given clinical situation or case.
There are two psychiatrists from the public sector commenting here, Dr. Dawson [Real Psychiatry] and Sandy Steingard [Mad in America]. I would recommend following what both have to say. Their views and temperments differ, but they both speak from the trenches of experience and are the kinds of people we need to be listening to. Another reference you might want to look at is the article After Newtown by E. Fuller Torrey, the author of the report Dr. Insel was referring to in the last post [lamentations · long passed…] to fully digest his point of view. That brings me back to the quote from Dr. Insel I started with: "Returning to the asylum system — which could be regarded as turning away from the goal of recovery — is not the answer." I found that odd when I first read his post, but I passed over it because I had something else I wanted to say.
The dichotomy between the asylum system and the goal of recovery uses phrases that have too many layers of meaning for that simple sentence. The asylum of Philippe Pinel or Dorthea Dix was as sanctuary for the humane treatment of the severely mentally ill. The asylum of the 1940s was an overcrowded snake pit where the severely mentally ill were essentially warehoused to keep them out of sight – forgotten people. While it’s hard for me to imagine not having the goal of recovery for all patients, that has to be defined for any given person because it varies over the a wide spectrum of possibilities. In this instance, I’m talking about the people with chronic psychotic illness who live in our prisons because there’s no other place for them that they can manage, and many are there by their own hand for that very reason.
I said at the outset that the Civil Rights Movement may have been the last time I was ever sure of anything, but I’m thinking that’s not really right. I’m sure that putting chronic mental patients in prison isn’t right – certainly not as a standard operating procedure. And that’s not an invitation for rounds and rounds of the divisive and blaming arguments that always swirl around this topic. I’m old and have heard them all. When I was suggesting a Task Force, I wasn’t thinking of the usual suspects – the mental health policy wonks from either side of any number of fences. I was thinking of people who have spent their lives among these patients and have a sense of what might work and what won’t. I would include judges, their jailers, and the patients who could participate. In my view, the blaming and arguing that invariably arises has actually interfered with any progress in the humane care of these patients. I’m sure that there’s something we can do that’s much righter than what we’re doing right now, and we’re obviously not doing it yet. I should actually say some things, because these patients are as varied as the rest of us even in their disability, and we need flexability to meet that diversity. There are templates aplenty to guide us. We are at the bottom of the heap among the countries of the developed world in this area, and I expect they’d fall all over each other trying to help us do things better.