HEALTH CARE/Joan Retsinas

The Mentally Ill: The Dialectic of Crisis, Solution, Crisis

Kudos to the Boston Globe’s Spotlight Team, the investigative unit that probed the data-mine of pedophilia within the Boston Archdiocese. One aberrant cleric was not a surprise. Fellow clerics and parishioners knew about each single instance. But the data yielded a pattern – and won the team a Pulitzer.

Spotlight has done the same with the neglect of people who are seriously mentally ill. The team began with a horrific case: well-intentioned clinicians and bureaucrats, following protocols, shunted a patient from home to hospital to clinic to jail to the street, back and forth, evoking a Feydeau farce, with doors opening, closing, re-opening. For this man, the last door closed tragically when, in a paranoid delusion, he killed his mother.

Mirroring the Globe’s investigation into pedophilia, the team dug into the statistics behind Massachusetts’ mental health system to find a pattern of patients whirling through their own Feydeau-like doors, back and forth and back again.

Later the team zeroed in another young man, driven to throw himself, armed, at police — a “police-assisted suicide.” Statistically, the Spotlight team probed “police-assisted suicides.” From 2005 to 2011, Massachusetts police killed 65 people: 31 were mentally ill, attacking police with a knife, a machete, sometimes a gun. Police shot and injured another 24 people who needed help. The team traced one/third of all police shootings to attackers who were mentally ill.

Massachusetts is not unique. Throughout the country, hospital emergency rooms are discharging patients diagnosed with mental illness too soon, with no backup. The Globe may win another Pulitzer. The crisis is alarming; the outrage, real. We have a victim: people with serious mental illnesses. We have a villain: a disjointed non-system of community services. But we don’t have a clear solution.

Telescope back 50 years, to another villain, another solution. In the not-so-long ago past, we relegated people with mental illnesses (as well as retardation and social deviance) to long-term hospitals where, optimistically, they would either get better, reform or live meaningful lives. Realistically, many patients languished, suffering from neglect and abuse. Writers spotlighted the horrors. Working as an orderly in a California mental hospital, Ken Kesey wrote One Flew Over the Cuckoo Nest. The subsequent 1976 film won five Academy awards. After stints of “participant observation” at a mental hospital, Erving Goffman wrote Asylums, describing inmates so “institutionalized” they could not live in the community. Those exposes led to outrage.

That outrage prompted reformers, abetted by the courts, to seize that era’s solution: de-institutionalization. With better drugs, people diagnosed with mental illnesses would live, with “supervision,” in the “least restricted environment.” We would shutter the awful, and expensive, institutions; at the same time, we would move patients to humane, and cheaper, community settings.

Cheap and humane: the twin goals never neatly dovetailed. But numbers-crunching state politicians clung to the specious linkage – not foreseeing the resultant social chaos (and expenses) when they slashed mental health budgets under the banner of a cheap, humane solution. (Of course, we haven’t totally shut down all mental hospitals: the ones that remain garner their own Pulitzer exposes.)

Indeed, step one in a “solution” is to recognize that there is no one solution. Every person needs to live in the least restrictive environment, as the law requires. But every person needs to live embedded in a community. T.S. Eliot wrote, “What life have you without community?”

“Community,” though, is not the street, an “independent apartment,” or an overwhelmed family. For some people, “community” will be a hospital; for some, a group home; for others, family, with a back-up crew of helpers and social workers, perhaps anchored in an outpatient clinic. Medication may be crucial, but so will oversight.

And the team — physicians, family, social workers and therapists — who construct the right “community” with and for each person should not be headed by a politician intent on short-term savings. In the long run, that is costlier, as well as crueler.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email

From The Progressive Populist, August 15, 2016

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