Mental illness presents us with many challenges in diagnosis and effective treatment. But the most serious of these issues surround the question of incarceration in prison or admission to a psychiatric hospital. This is most noticeable when the issue at hand is murder by an individual with a serious mental illness.
Recently, a young woman living in New York City returned to her apartment, and a homeless man slipped through the locked entrance before it closed behind her. Following her up the stairs, he would murder her with a knife from her own kitchen.
Exhibiting a lack of escape plan, he barricaded himself in her apartment, forcing the police to break down the door. Calls to 911 by neighbors hearing a woman’s screams alerted them to the situation. The man was arrested and taken into custody, and he may be charged with a hate crime; the woman was Asian-American. Sources investigating the case found the man had multiple instances of criminal behavior and was released on his own recognizance.
This man is one of many who have fallen through the cracks in a mental health system in tatters and created by the well-meaning but inadequately managed deinstitutionalization movement after 1955, which picked up steam in the 1970s.
Unfortunately, it’s not the first time an individual in dire long-term need for care and treatment was left wandering the streets to assault and, in one case, murder a therapist in her office in New York City. The trial and that man’s insanity defense failed to place him in a hospital, and he went to prison.
With the closing of large, self-contained psychiatric hospitals that functioned much like small towns, many patients were sent to live in supervised housing or apartments or with their families. Promises of ongoing care and careful follow-up never materialized to the extent needed, and patients became homeless.
In some cases, repeated incidents of street or subway attacks never resulted in long-term care under strict supervision. Prisons became the “hospitals” for these patients who were now criminals. However, press coverage can lead the public to believe that all patients with a psychiatric illness are potential criminals or murderers, not so.
If the system is failing both the patients and the public, what possible solutions might there be that would meet the needs of both? One, of course, would be a return to the former hospital system where patients could live out their lives. I’m not sure the bucolic moral treatment existence related to me by old-time hospital staff was accurate, but it may have been better than our current state of affairs. Unfortunately, that wasn’t a time of intense data collection, so we have nothing to go on regarding incidents of criminality by the mentally ill.
I’ve worked in these hospitals, I’ve seen patients who could be safely returned to the community and ones that might never recover a rational ability to function outside the institution. One patient who was delusional and had killed his mother kept muttering that all women must die.
Patients on wards where I’ve worked had received treatment from insulin coma therapy, ECT, lobotomy, psychotropics, and behavioral therapies of many types.
Management at the hospitals wasn’t akin to anything resulting from an MBA. Some patients were “treated” with questionable psychotherapeutic techniques as they cycled through the wards. Therapists were unlicensed, physicians weren’t necessarily psychiatrists, and some were pediatricians in a hospital for adults.
The diagnoses ranged from mental developmental disorders, drug-induced delusions, to paranoid schizophrenia. And some of them had murdered one or many people. I worked with those patients, and I know some, who killed their entire families, did so by psychotic reasoning brought on by severe, extended stress. One wanted to die so he could join his family in heaven.
Today, I’m sure many of them live in communities near or far from the hospitals. I am not sure whether some of them would not have another break in their reality testing ability. Often, taking prescribed medication requires a level of care that is either lacking or there is resistance and discontinuance.
Do the mentally ill have constitutional rights regarding psychotropic medications and hospitalization, and how should these individuals be protected? One significant case brought before the US Supreme Court was a clever test of the issue of involuntary detention in a psychiatric hospital.
The case of Kenneth Donaldson was simple. Donaldson refused to take psychotropic medication, and because the hospital was not treating him, he argued he should have been discharged.
After the case was decided in his favor and the court agreed that Donaldson could sue those who took his freedom from him, he would write a book and be interviewed for a podcast. Today, in hospitals, we have legal procedures where psychiatrists decide whether a resistant patient needs meds, and they may then be forcibly administered.
Involuntary hospitalization remains one means of protecting those with mental disturbances from harm to themselves or others, but the question of competence remains. The statutes for obtaining orders to forcibly detain them vary by state, and they are known by many names. In Florida, it’s “Bakering” or the Baker Act. Most provide for several days of hospitalization before a person may request discharge if the medical staff agrees the current need for stabilization is over.
Where do we go from here? One aspect of this serious dilemma remains questionable; funding. If inadequate funds are authorized or poorly utilized when authorized, who will protect both patients and the public? Who is responsible for deaths and destruction of property when a patient is left to wander the streets and had been discharged to a community residential facility?
How much supervision do they receive in those residential housing units? I know of some places where staff leaves at 4 pm each day. There is no overnight coverage in the residence.
I remember a hospital worker once commenting on the excessive discharges of patients unready for release. “She’ll discharge them to a crate in the middle of the street.”
Civil rights and mental health issues clash frequently, and the outcomes are not precisely what is needed unless knowledgeable, caring, and prolonged planning is created. I once offered training for judges hearing mental health disability cases and never received a response. What type of training do judges receive in this area? I question whether they receive any.
The current state of affairs ensures that people will wander, people will be seriously injured or die, and the media will howl each time. But who will step up and attempt to fix the broken system? Anyone who presents themselves must be prepared for a rain of ire and accusations. It is not a pretty picture.