Former State Legislator Paul Gionfriddo’s anguished account of his son’s schizophenia is a must read:
In 2008, at age 23, Tim moved to San Francisco and has lived mostly on the streets there ever since.
The last time I visited him, he was holed up for a while in a small room a caseworker had found him in a Mission District rooming house. His only furniture was a bare mattress on the floor; a rat and flies were his companions. Sadly, he seemed content.
This is the mental health delivery system that I helped build.
I have to admit I think this is a terrible piece.
It IS a tragedy that we have no reliable way to cure (or even ameliorate) schizophrenia.
It IS also a tragedy that we have a mental health system that can’t help those who do want help.
But these two are not tied together.
Look at that sentence “Sadly, he seemed content”. This is not nonsense. I know someone who looks to me like they are becoming a schizophrenic before my eyes. They have exactly the pattern of forward then backward motion, of successes in college followed by some months of living on the street, that I have seen in books I’ve read on the subject, and that we see in this story. But, and this is essential, he does not appear to understand that there is a problem here. Once again this is not uncommon — Ellen Saks in her book talks about how it was only in her late 30s or so that she truly understood that she was actually different from people around her.
So what do we do about this? Forget the issue of the mental health system — assume all the money in the world. That is NOT the problem. The problem is: either we assume people in this state have the capacity to make decisions or they don’t.
If they have that capacity, well they are choosing to live on the street — including all that entails in terms of self-medication via crack, meth and bath salts.
If they don’t have that capacity, we can certainly lock them in a mental hospital and force them to take one anti-psychotic after another. This is not necessarily a council of despair. Some of the modern anti-psychotics do work well. But it’s a struggle to find ones that work for each individual, they can have nasty side-effects, and the patient may be fighting each step of the way. And that means, at every stage of the way you are forcing a person (who at least occasionally seems lucid, intelligent, and competent) to do something they don’t want to do. America had a system something like that until the 70s, and it was dismantled because people felt very uncomfortable with this. And that was when America was happy to be a whole lot more paternalistic than the Libertarian America of today.
The point is — I’m not sure that the mea culpa here is at all justified. We (US society) have no coherent idea of how to handle this situation.
For example Gionfriddo complains that schools and hospitals are not doing enough to catch and help such kids. On the other side, you have a huge chorus against DSM (in any of its forms) and the complaint that schools/hospitals/doctors are far TOO eager to diagnose a variety of mental disorders in young kids and to start feeding them pills.
Looking at all this as an outsider, to me the articles smacks far too much of legislation (or would-be-legislation) by anecdote. And these sorts of wild swings — from anguish over (a few? many?) cases in the 70s is what got us to the situation Gionfriddo is complaining about.
FAR more useful, IMHO, would be to approach the problem like an engineer. Accept that perfection is not possible and start asking for numbers.
What are the consequences (the equivalent of false positives and false negatives) of various regimes? What are the most rapid ways to winnow out the truly sick (schizophrenia for example) from the “mentally competent” sick (eg depressives) from the merely boisterous or temporarily unhappy? What is the most effective order of drugs to try against schizophrenia to try to get to clarity ASAP? Can one learn things from other countries? )Eg Ellen Saks talks quite a bit about how much less “militarized” UK mental health facilities felt compared to the US, and how much more comfortable that made her feel — which results in things like being more willing to check-in voluntarily.
What is not helpful is articles that try to swing public opinion from one extreme (we will never have a false positive again!) to the other extreme (we will never have a false negative again!) without any acceptance that this is a truly hard problem, that mistakes are made no matter what is done, and that perhaps the solution isn’t more or less money, more or less laws, it is
(a) a regime that is optimized (by people who know what they are doing) to balance all the very concerns AND
(b) more KNOWLEDGE, so that every professional, every hospital, every school, isn’t constantly re-inventing the wheel.
But lawmakers (and parents, and everyone else) have to accept that perfection is not possible. We can’t respond to One Flew Over the Cuckoo’s Nest by letting everyone on the street, then respond 30 years later, when one lawmaker’s family has an individual tragedy, by one again starting from scratch and putting everyone back in hospitals against their will.
I worked for a while in a voluntary residential care facility for the insane. They could come and go as they pleased, we provided services such as medication delivery, counseling, group therapies, etc. There was a lot to like about it.
Unfortunately, it was terribly unfunded. We couldn’t afford adequate janitorial services. The buildings were in disrepair. The staff was mostly under-qualified. The services felt ad hoc and unfocused. As a basic model, it was pretty good. But it could have been a lot better with better funding.
I think that this kind of dichotomous argument is not terribly helpful. There are many medical conditions where we recognize that people have impaired cognition and are unable to make some kinds of decisions while perfectly capable of making others. The choice isn’t simply “let them fend for themselves” or “lock them up”.
As Eli points out, there is a lot you can do to make the lives of mentally ill people better without resorting to lockup coercion. It’s just way more difficult to administer.
The comment is spot on. The anecdotal informing the structure takes us in circles . I’m an actor take this warning, do not listen to the play if you are not in the theatre. The problems are real, require the concerned effort of generations of dedicated work to ameliorate and if possible resolve. If we remain decent and lucid and caring we might hope for better.
Unlike anonymous, I read the article not so much as a plea for action but simply a personal account with a plea for compassion toward the mentally ill. It’s true there was a bit of “if I could do it over” language at the end but I don’t think the author was trying to make a case for a “Tim’s Law”. Indeed, an important aspect of his story is regret over legislating without a full set of facts. I do wonder whether he’s really prepared not to make the same kinds of mistakes. Anonymous is right that there isn’t a clear way forward. We would do well to recognize that.