Just a Little, But Never Enough: Failing Those With Serious Mental Illness

In the context of mental illness, I once held the belief that as long as someone wasn’t a harm to themselves or others, they should have the freedom to roam free no matter how dysfunctional they may be. But after my own experience with involuntary hospitalization resulting from a psychotic episode, I was sent on a different journey that brought with it the realization that forcing treatment is a complex issue, and it sometimes can be the most compassionate thing to do.

There was no question in my case as to whether I needed involuntary hospitalization. I thought there was a conspiracy to kill me and reacted consistent with that delusion when I protected myself and hurt someone I care about. During the episode, I did not believe I was ill at all. There would have been no convincing me that my interpretation of the world was wrong. And I trusted no one. While my hospitalization was awful – a separate but related issue – it was most definitely necessary.

In cases like mine, maybe there isn’t too much disagreement on whether people should face involuntary hospitalization. But it seems to become grey when someone is obviously mentally ill and suffering, homeless, unable to care for themselves in terms of basic activities of daily living, and experiencing a multitude of physical health challenges. In many cases a substance use disorder is also present. Often there is not enough to involuntarily compel treatment here.

Having worked with those whose lives have been complicated by serious mental illness and addiction for the last five years has led me to the opinion that definitions of “harm to self” and even “harm to others” probably needs expansion. Most maintain the belief that those with mental illness and addiction do not belong in jail – particularly when alleged criminal activity is a foreseeable consequence of untreated illness. And I agree with that. But the solution shouldn’t be the freedom to suffer miserably from ones’ illness and to continue the commission of low level crimes which become excused without any treatment rendered. Harm to the individual and societal harm results from failure to treat.

There’s an irony in that arguing against involuntary care inadvertently supports a different type of prison, which is the one that comes from being captured by a relentless and unforgiving darkness that has the capacity to control our thoughts and behavior. I’ve taken care of homeless folks with serious mental illness covered in sores and suffering infestation, many also had broken teeth and abscesses with no access to dental or physical health care. Many time they aren’t considered ill enough to force any level of treatment. The suffering continues and many die without care. They are victims of a system that doesn’t do nearly enough to provide anything of substance to help them.

One primary issue is that even if we decided we wanted to force treatment or utilize existing laws such as assisted outpatient treatment, we have a severe scarcity of programs in place that follow evidenced based practices to help people live safely, and with meaning and purpose. As this system is now, we cannot help those who need it the most and we keep them from realizing their full potential.

Crisis services are necessary and important, but they are hardly sufficient, and they are ineffective at achieving long-term positive outcomes. Inpatient hospitalization is a revolving door because people discharge to nowhere. And some folks with illness will end up in jail regardless – many due to criminal activity related to illness, and some unrelated to illness. They get swept up in legal processes which are a waste of time and money, and those processes also provide no real treatment or care. What may actually lead to results is to provide mental health and addiction services in jails and prisons that meet medical and nursing standards of care with no participation exclusions, diversion programs that accept a wide variety of cases that offer mental health and addiction treatment, and an ability to force treatment in both the inpatient and outpatient setting when people are suffering severely and perpetually from their illnesses. For those unfortunately swept into the criminal system, we need treatment as soon as possible, a way out, and we need options for them to wipe out their criminal history when appropriate. Of course, comprehensive high quality community programs are necessary to make anything work at all. Further all treatment environments – jail, hospital, or otherwise-  should aim to provide compassionate, evidence-based care. Otherwise, what are we doing?

What we have is a cycle of crisis. We are essentially playing Whack-A-Mole at all levels, but it involves real lives. It’s because we do just a little, but never enough.