Tragedy spotlights legal limits on treatment for mentally ill
murder of so many children and their teachers in Newtown, Conn. is a terrible tragedy for the nation; made greater by the fact that it is one of many.
One of the issues uniting the Columbine shooters, SeungHui Cho (Virginia Tech incident), Jared Lee Loughner (Giffords), James Holmes (Aurora) and Adam Lanza is their history of mental illness and the failure of society to deal with it. In 1955, there were nearly 550,000 patients with mental illnesses in state hospitals. The U.S. population has doubled since then, yet the population of persons in state hospitals has fallen to less than 100,000.
There are good reasons for some of this decline.
Antipsychotic medication, developed in the 1950s, was not a cure for schizophrenia but allowed many patients to function more fully in society (when it was taken). The Supplemental Security Income (SSI) program provided a meager income to those mentally ill who were unable to work.
Those patients who did leave the state hospitals were supposed to be cared for in community mental health centers, such that in the 1960s, mental health professionals looked forward to a new era in the treatment of mental illness involving community services and intensive rehabilitation services. Then it all went horribly wrong.
Today, we have thousands of mentally ill persons wandering our streets or living in boarding homes, refusing to take medications and, in some cases, committing acts of aggression against themselves, their families and the community. Many people have “a state hospital in the back bedroom” — a child or sibling who withdraws from society and shows signs of serious mental illness. Adam Lanza, by reports, showed this pattern — an early history of withdrawal, poor social skills and lack of functioning in daily life. There appears to have been no particular trigger for his behavior — but he was at the age that many with serious mental illness have their first episode of psychosis. His mother was worried about him — but where would she have gone, especially if he did not wish to seek treatment? She would have found few options.
What got us on this track? In 1975, in O’Connor v. Donaldson, the Supreme Court sharply restricted involuntary hospitalization, and any treatment had to take place in the “least restrictive environment.” Today, commitment procedures are difficult to initiate and require imminent danger. Subsequent court decisions have prevented mandatory treatment of the mentally ill except in “emergency” situations and established a “right” to refuse treatment. In essence, this means that even an involuntarily committed patient cannot be made to take medication once released from a hospital. All of these decisions are based on a false premise: that being mentally ill is a lifestyle choice that should not be interfered with unless there is “danger to self or others.” But schizophrenia and manic-depressive illness are brain disorders which rob a patient of insight; even when there is no overt danger the patient still suffers. We would not leave an epileptic to lay seizing on the street, so why do we allow a schizophrenic to wander the streets talking back to tormenting voices?
The concept of “least restrictive treatment” led to the concept of a “right” to community as opposed to hospital treatment of mental illness. Today, there are so few long-term hospital beds that even patients who want to be admitted often are not. We do not want to go back to the days of state hospitals located in rural areas far from families and qualified staff. Patients who are well situated in the community should remain there. We need, however, a wholesale re-examination of American mental health care policy of the last 50 years. If we place more barriers to the treatment of the mentally ill, then the Newton tragedy may be repeated many times more.