Two mobilizations of historic enlightened reform are abruptly converging in American politics and policy. Their aims are intertwined: to bulldoze and rebuild our blighted structures of criminal justice, and to reclaim our dispossessed mentally ill brothers and sisters from the hellscape of danger, pain, and early death that the blight of justice confers on them. And the economic drain that it exacts from all of us.
The symbiotic forces are (1) the elite tier of progressive candidates for the 2020 presidential election, and (2) the sleeves-up cadre of activists working at Ground Zero who toil because they daily confront serious mental illness up close, and witness its effects for what they are: cancers upon our societal health and sense of decency.
(The first of two parts)
At first glance, justice and mental-healthcare reform may seem but a marginal sliver of all the issues pressing in on America in the 2020 elections. (The physical salvation of the planet comes to mind, and abolishing the immigrant gulags at our southern border.)
This is a distorted, damaging perception, made more dangerous because the crisis is so easily concealed. It can sometimes seem as though insanity and incarceration are like two undersea predators, their tentacles wrapped around each other in a death-struggle of futility. The quality of courts, jails, and prisons has been weakened by years of tending people who should be under psychiatric care. The essentially helpless 11.2 million seriously mentally ill population in turn is vulnerable to suffocation in the folds of feckless court rulings and inhumane treatment behind bars, including deprivation of essential meds and the beckoning maw of solitary confinement (about which more—much more—later.) The one in five adults with less chronic afflictions—nearly 47 million—are within range of the tentacles as well.
Yet that perception, or lack of perception, prevails. It prevails because to open our eyes to the full truth of these abominations is to risk scorching the soul. “I’ll do what little I can in writing,” lamented the great James Agee in another, and again oddly similar context some 75 years ago. “Only it will be very little. I’m not capable of it; and if I were, you would not go near it at all. For if you did, you would hardly bear to live.”
Thus we banish the ghastly effects from our attention as “normal” Americans, until it is too late. The entwined crises strike quickly, and from nowhere, and spread ruin: in households and communities (black and poor ones especially), in the workplace, in public places, in our economic state, and in the less tangible spheres of our collective optimism, hope, and peace of mind.
America has needed an “intervention” for more than two centuries. Intervention seems, at last, to be on its way.
The most ambitious manifestos, in my unscientific reckoning, were issued within the last ten days by Senators Bernie Sanders and Elizabeth Warren and South Bend, Indiana Mayor Peter Buttigieg. Nearly as powerful were the earlier justice reform announcements of Cory Booker, Amy Klobuchar, and Julian Castro. Joe Biden and Kamala Harris submitted strong, if not notably comprehensive, reform ideas.
This ranking hierarchy is not as fixed as the tiers might imply. The eight plans are far more significant for their overlapping reform goals they stress than for their differences.
Slashing into federal prison glut is high on most lists. Sanders, Warren and Buttigieg unveiled proposals that would cut into mass-incarceration, each by roughly 50 percent: by reducing long sentences, ending the “cash bail” system that pauperizes poor families of those arrested, tightening up on police oversight, legalizing marijuana, and abolishing private prisons. Sanders’s document, at 6000 words, is by far the most minutely detailed. Warren would go after policies that “criminalize” homelessness, poverty, and mental health problems (critically, she has not elaborated on this last). Booker would scale back inmate numbers via a clemency program that would free many elderly inmates under the theory that criminals “age out” of their impulses to commit violent crimes. Klobuchar also embraces clemency via a restructured reform plan and would modify the “tough-on-crime” stances she held as a prosecutor in Minnesota.
Castro’s vision is likewise far-ranging, but he places special emphasis upon overhauling violent and clueless behavior of policemen. He wants to curb the use of force, end stop-and-frisk, holding police more accountable for misconduct, and restoring trust among police and the communities they are sworn to protect.
As for Biden and Harris, their reform plans are similarly comprehensive and replicate the bold ideas of their rivals as listed above. Both candidates—and to some extent Klobuchar as well—are preoccupied with freeing themselves from the taint of the “tough-on-crime” stances that they adopted in the mid-1990s.
That is my personal survey, unfairly truncated perhaps, of the generally ground-breaking flurry of criminal-justice reform ideas released by eight of the leading progressive presidential candidates.
An obvious but important caveat: none of these audacious ideas will tap-dance its way into law or policy should its sponsor get elected. (The proto-autocrat decrees of our current incumbent might lull some into that assumption.) A new chief executive will need to inspire the House and Senate to a pitch of pro-active fervor not seen since the First Hundred Days of Franklin D. Roosevelt’s presidency when the New Deal took form in a blizzard of “relief, recovery, and reform.” For our present stumbling and divided Congress to suddenly sprout capes, masks, and flippers and get busy cleaning out the present rot may seem a stretch. Yet things can happen quickly, as the last midterms showed, and a whiff of activism does linger in the air.
With all this in mind, let us turn to the symbiotic manifesto that has arisen from those ordinary heroes at Ground Zero: “Grassroots 2020: A 5-Part Plan for Mental Illness SMI.”
Grassroots: 2020 has been personally distributed to visiting Democratic candidates or mailed to their offices by Leslie and Scott Carpenter of Council Bluffs, Iowa. The Carpenters’ tireless work has helped join the reformist trajectories of these politicians and the people.
I lay it out below with minimal editing, in summary form. You will note that each part of the plan delineates action that a president can undertake, sometimes independently of Congress. And unlike the candidates’ ideas above, Grassroots: 2020 addresses justice-reform issues (incarceration-trimming, for example) only incidentally. It focuses on existing rules, many of them arcane to the non-specialist, that nonetheless have caused decades of frustration and despair for those struggling to reclaim their afflicted loved ones from a decayed system:
A FIVE-PART PLAN TO ADDRESS SERIOUS MENTAL ILLNESS (SMI) 2020 PRESIDENTIAL CANDIDATES. PLEASE ADDRESS THESE TOPICS IN YOUR CAMPAIGN APPEARANCES AND DEBATES:
1. RECLASSIFY SERIOUS MENTAL ILLNESS (SMI) FROM A BEHAVIORAL CONDITION TO WHAT IT IS – A NEUROLOGICAL MEDICAL CONDITION
WHY RECLASSIFICATION IS IMPORTANT:
Re-classification will unlock more research funding and help eliminate discrimination in treatment, insurance reimbursement, and the perception of SMI as a “behavioral” condition. SMI is a human rights issue. The National Institutes of Mental Health ranks SMI among the top 15 causes of disability worldwide with an average lifespan reduction of 28 years.
• Create a cabinet position exclusively focused on SMI. • Push for Congressional appropriations to include schizophrenia in a CDC2 program that collects data on the prevalence and risk factors of neurological conditions in the U.S. population.
2. REFORM THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)3
WHY HIPAA REFORM IS IMPORTANT
Overly strict HIPAA laws make it extremely difficult for families and caregivers to partner in the treatment of their loved ones, resulting in important life-saving medical information gaps. By eliminating this barrier, family support will be strengthened, reducing the chance of relapse, homelessness, imprisonment, and death.
Work with legislators to change HIPAA law to ensure mental health professionals are legally permitted to share and receive critical diagnostic criteria and treatment information with/from parents or caregivers of SMI.
3. REPEAL MEDICAID’S INSTITUTES FOR MENTAL DISEASE EXCLUSION (IMD).
WHY IMD REPEAL IS IMPORTANT:
The Medicaid IMD Exclusion prohibits Medicaid payments to states for those receiving psychiatric care in facilities with more than 16 beds for those in the 21-65 age group. This demographic represents the majority of SMI cases. Repeal of the IMD Exclusion will increase the availability of acute care, inpatient psychiatric beds. The IMD exclusion not only discriminates against those suffering from neurological brain disorders, it’s a leading cause of our national psychiatric hospital bed shortage.
• Work with legislators to repeal the IMD exclusion.
4. PROVIDE A FULL CONTINUUM OF CARE FOR THOSE WITH SMI
WHY A FULL CONTINUUM OF CARE IS IMPORTANT:
A continuum of care insures that SMI patients receive early intervention at all stages of their illnesses, long-term care when needed, and follow-up treatment (medications and therapies) when they’re released. Providing a continuum of care reduces: incarcerations, emergency rooms visits, homelessness, and death. A continuum of care provides life-time management that permits a patient to move without penalty from one level of care to another as needed.
• Create federal incentives to states which are addressing a full array of inpatient, outpatient, and supportive housing care.
5. DECRIMINALIZE SERIOUS MENTAL ILLNESS (SMI)
WHY DECRIMINALIZATION OF SMI IS IMPORTANT:
People suffering with other neurological conditions like Alzheimer’s and dementia can get treatment promptly without being kicked out of their homes to wander the streets until they are arrested and put in jail or prison rather than a hospital. Serious mental illness is the only disease where the doors to treatment are shut unless a crime is committed. This is pure and simple discrimination with the disastrous results we see in our country today — homelessness, incarceration, the disintegration of families, and death.
• Work with legislators to change “must be a danger to self or others” criteria. • Work with legislators to change involuntary commitment criteria, alleviating the subjective nature of “gravely disabled” and redefining it in objective terms based on scientific medical need for treatment. Psychosis, like a stroke, is a traumatic brain injury and needs immediate treatment for the best outcome.
Returning to the candidates’ manifestos, I have omitted two demands that show up in most of them, yet are given no more than lip-service by none except Bernie Sanders: abolishing capital punishment and solitary confinement. Both are urgent. Deciding which is the most urgent depends, I guess, upon the morbid calculation of whether continued existence in the “hole,” with its barbaric history of destroying human personality, is worth the torture. I have felt my way to an agonizing decision. In my next blog I will urge the candidates to meditate on solitary confinement for exactly what it is, and to treat it as primary target for abolishment.
The documents below usher in a revolution. They describe a bold new movement, a national front organized to break the silence of the stricken and reverse the longstanding political neglect of America’s decrepit mental healthcare policies and institutions.
The advocate and author (Sooner Than Tomorrow) DeDe Ranahan has completed a wide-ranging national canvass of those in the “sub-nation”: the mothers, caretakers and advocates of people suffering from serious mental illness: schizophrenia, bipolar disorder, and related incurable afflictions.
Her tireless work has produced historic results: the first comprehensive, deeply informed list of things that absolutely need to be done to restore safety, humanity, and hope to a strata of victims that has been marginalized and abused since medieval times.
The dynamic advocacy team of Scott and Leslie Carpenter is distributing these documents to the candidates visiting Iowa prior to the Democratic presidential primaries. The Carpenters have reported that the response so far has been heartening.
DeDe Ranahan’s survey results are vital both in themselves and as building-blocks toward a future unification of efforts to reclaim the mentally ill and restore them to meaningful lives. She deserves the thanks of everyone who has been touched by this abhorrent malady. It seems that someone, after all and at long last, does care about crazy people.
TO: All 2020 Presidential Candidates
SUBJECT: Serious Mental Illness (SMI)
So far, 2020 political candidates make rare mention of serious mental illness (SMI — schizophrenia, schizo-affective disorder, OCD, bipolar disorder, and major depression), and the lack of mental illness care in the US.
* The SMI population represents 4-5% (10 million) of the mentally ill in the US. That’s 10 million families and extended families (voters).
* Ten times as many people with SMI are incarcerated as are hospitalized.
* Some SMI individuals are so sick they don’t realize they’re sick (anosognosia), don’t respond to treatment (if they get it) and end up incarcerated, homeless, missing, suicidal or dead.
It will cost billions to create a viable mental illness system. It’s costing billions, now, in prison over-population, homelessness and cities under siege, lost workdays, family disintegration, suicides, untimely deaths, inundated ER’s and hospitals, violence caused by untreated SMI, overwhelmed police, and in uninformed and misinformed criminal justice systems.
The Five-Part Plan enclosed is the collaborative work of grass-roots advocates from across the country —individuals, professionals, writers, journalists, caregivers, and mothers (always the mothers). Our intent is to put this plan in front of every 2020 presidential candidate. Right now, no candidate is talking about SMI. It’s as if it didn’t exist.
The steps in our plan are baby steps. We can’t immediately address everything that needs to be addressed in our messed up mental illness system, but we have to start somewhere. We’re trying to help 2020 candidates — we know you have a lot on your plates and we appreciate your energy and efforts to make our country better. We’ve created this Five-Part Plan to give you a starting point and a way to introduce SMI into political discourse and public conversation.
We’re asking you to take four initial actions:
1. Please read our plan and make it your own.
2. Put your SMI plan on your campaign website.
3. Talk about SMI on the campaign trail and in campaign debates.
4. Talk with members of the SMI community. We’re willing and able to help you as you move forward.
The SMI community is searching for its 2020 presidential candidate. We’re a large, passionate, motivated, frustrated, hurting, and determined block of voters. We look forward to hearing from you.
Marie Abbott — Waterford, Michigan,
“My grandson has autism, bipolar disorder, and development delays. Has his civil rights intact.”
Jane Anderson — Illinois
“My 38 year-old son has paranoid schizophrenia. He was diagnosed at 18. My husband and I are caregivers.”
Tim Ash — Arcata, California
“Caretaker of a volatile, unstable SMI family member because there are no options besides jail and the bushes or doorways.”
David Bain — Sacramento, California
“I’m living with chronic depression and epilepsy and working to divert SMI from prison into treatment.”
Marti Rhoden Bessler — Alexandria, Kentucky
“My son’s been suffering from schizoaffective disorder for 19 years within our failed mental health system.”
Alisa Bernard — Jupiter, Florida
Judy Bracken — San Ramon California
“My 30-year-old son has schizoaffective disorder.”
Katherine Smith-Brooks and Bob Brooks — Carlsbad, California
“Our SMI son is now stable and working following effective treatment and the same psychiatrist for 20 years. We were his only advocates for many years.”
Regina Gipson Burns — Hoover, Alabama
Leslie and Scott J. Carpenter — Iowa City, Iowa
“Our son’s been suffering from under-treated schizoaffective disorder for 12 years. He lives in a group home with too few services. He’s been hospitalized 20 times.”
Sue Chantry — Vacaville, California
“I’ve lived here for many years and watched Mark Rippee, SMI and blind, on the streets of Vacaville with no mental health services.”
Barb Cobb — Iowa
“My SMI daughter’s been under-treated and under-supported by the current system. She’s endured over 20 hospitalizations and is barely surviving.”
Christine Cushing — Vacaville, California
“There are no resources or places to live for those who suffer from SMI. For a country that’s so progressed, we’re so far behind taking care of those with SMI.”
Lori Daubenspeck — St. Croix, US Virgin Islands
“My SMI son is a US Army vet. There’s no SMI facility here and one psychiatrist for the island. We’re in desperate need of facilities, doctors, and federal action.”
Kathy Day — Folsom, California
“My godson’s been discharged from hospitals many times while considered to be gravely disabled. Laws need to be based on need for treatment rather than time.”
Katherine Flannery Dering — Bedford, New York
“My brother, Paul, suffered with schizophrenia for 32 years of dwindling care. He died at age 48. “
Lois Earley — Phoenix, Arizona
“I’m the mother and legal guardian of an adult SMI daughter. I’ve been battling the behavioral health care system in Arizona since 2004.”
Darla Eaves — Everett, Washington
“My husband committed suicide. My son died in our psychiatric hospital. My daughter, thank God, is here with me and stays on her medication.”
Donna Erickson — Abington, Massachusetts
“My 34-year-old son has bipolar disorder. He’s been hospitalized 25+ times and cheated out of the life he wanted through no fault of his own.”
Sonia Fletcher —- Mount Shasta, California
“My daughter’s SMI was untreated when she shot and killed her father in a psychotic break. Our family is heartbroken and literally broken apart.”
Anne and Tim Francisco — Orange County, California
“Our SMI son was sentenced to prison for a nonviolent offense while he was in a state hospital. He ended his life by suicide while in solitary confinement.”
Lynne Gibb — Ojai, California
“My daughter’s suffered with schizo-affective disorder for 20 years. She’s been missing, homeless, and hospitalized, but never out of her family’s hearts and thoughts.”
Elaine D. Gilliam — Myrtle Beach, South Carolina
“My eldest son has paranoid schizophrenia. My eldest daughter committed suicide. Two children are wonderful retired military families.”
“I’m the father of two sons afflicted with schizophrenia. One took his life in 2005.”
Paula and Bruce Quertermous — Clinton Township, Michigan
“Our 39-year-old daughter has bipolar disorder and cognitive disability from birth.”
Dede Ranahan — Lincoln, California
Author: Sooner Than Tomorrow—A Mother’s Diary About Mental Illness, Family, and Everyday Life (2019). soonerthantomorrow.com. “My son died in a hospital psych ward in 2014. “
Margaret Reece and Greg Gazda — Butte County, California
“Our SMI son has been hospitalized 5 times, arrested, and is currently in a mental health court program and living in Yolo County with his grandparents.”
Arlene Renslow — Modesto, California
“I have two sons with brain damage. One son has schizophrenia. Unless someone does something, things will get worse for everyone.”
Mary (Courtney) Sheldon — Poway, California
“Mother of 24-year-old SMI son. We’ve winged it for 5 years. My SMI brother died, with his ‘civil rights intact’ behind a dumpster in Anaheim, California.”
Martha Mccollister Sroka — Dunkirk, New York
“My son has schizophrenia. It’s horrible watching your child change, struggle, and suffer. I request that SMI get the same attention and resources as any other medical illness.”
Joanne Strunk — Lexington, Kentucky
“My daughter’s been raped, homeless, hospitalized (40+times), and almost died lost in the woods for weeks. She’s dying of neglect due to SMI.”
Shelly and Scott Switzer — Sandpoint, Idaho
“We’re parents of a 33-year-old son with inadequately treated schizoaffective disorder in Missoula, Montana. SOS We’re barely hanging on.”
Diana Mandrell Troup — Texas
“My daughter spent 16 years in delusion and psychosis because of bad mental health care. She suffered 50+ involuntary holds, multiple tazings, and traumas.”
Laurie Turley — Maine
“My sister died due to HIPAA restrictions. One of the last things she said to me was, ‘They should have let you help me. I wasn’t in my right mind.’”
Monica and Kimmo Virtaneva — Hamilton, Montana
“Our son, Mika, took his life after the disease schizophrenia took his brain and the criminal justice system took his dignity.”
Cheryle Vitelli — Newark, Delaware
“I lived with my SMI son for 6 years while he was dangerous with only he and I in the house. Finally, a compassionate police officer pushed to get him help.”
Darlene Been Watkins — Moulton, Alabama
“My son, Shane, was denied treatment, while in psychosis, because there weren’t enough beds. Two days later, he was shot by police while I watched.”
Anna Wellnitz — Oro Valley, Arizona
“I’m diagnosed with SMI.”
FIVE-PART PLAN TO ADDRESS SERIOUS MENTAL ILLNESS (SMI)
FOR ALL 2020 PRESIDENTIAL CANDIDATES
PLEASE ADDRESS THESE TOPICS IN YOUR CAMPAIGN APPEARANCES AND DEBATES
1. RECLASSIFY SERIOUS MENTAL ILLNESS (SMI)) FROM A BEHAVIORAL CONDITION TO WHAT IT IS, A NEUROLOGICAL MEDICAL CONDITION WHY RECLASSIFICATION IS IMPORTANT Reclassification will unlock more research funding and help eliminate discrimination in treatment, insurance reimbursement, and the perception of SMI as “behavioral” condition. SMI is a human rights issue. NIMH ranks SMI among the top 15 causes of disability worldwide with an average lifespan reduction of 28 years. PRESIDENTIAL ACTION * Create a cabinet position exclusively focused on SMI. * Push for Congressional appropriations to include schizophrenia in a CDC program that collects data on the prevalence and risk factors of neurological conditions in the US population.
2. REFORM THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPPA) WHY HIPAA REFORM IS IMPORTANT Overly strict HIPAA laws make it extremely difficult for families and caregivers to partner in the treatment of their loved ones, resulting in important life-saving medical information gaps. By eliminating this barrier, family support will be strengthened, reducing the chance of relapse, homelessness, imprisonment, and death. PRESIDENTIAL ACTION * Work with legislators to change HIPAA law to ensure mental health professionals are legally permitted to share and receive critical diagnostic criteria and treatment information with/from parents or caregivers of SMI.
3. REPEAL MEDICAID’S INSTITUTES FOR MENTAL DISEASE EXCLUSION (IMD) WHY IMD REPEAL IS IMPORTANT IMD repeal will increase the availability of psychiatric inpatient beds. The IMD exclusion is not only discriminatory of those suffering from neurological brain disorders, it is a leading cause of our national psychiatric hospital bed shortage. It prohibits Medicaid payments to states for those receiving psychiatric care in a facility with more than 16 beds who are 21-65, the age group with the most SMI. PRESIDENTIAL ACTION * Work with legislators to repeal the IMD exclusion.
4. PROVIDE A FULL CONTINUUM OF CARE WHY A FULL CONTINUUM OF CARE IS IMPORTANT A continuum of care insures that SMI patients receive early intervention at all stages of their illnesses, long- term care when needed, and follow-up treatment (medications and therapies) when they’re released. It reduces visits to jails, ER’s and hospitals, homelessness, and morgues. A continuum of care provides life-time management. PRESIDENTIAL ACTION * Create federal incentives to states which are addressing a full array of inpatient, outpatient, and supportive housing care.
5. DECRIMINALIZE SERIOUS MENTAL ILLNESS (SMI) WHY DECRIMINALIZATION OF SMI IS IMPORTANT People suffering with other neurological conditions like Alzheimer’s and dementia can get treatment promptly without being kicked out of their homes to wander the streets until they are arrested and put in jail or prison rather than a hospital. Serious mental illness is the only disease where the doors to treatment are shut unless a crime is committed. This is pure and simple discrimination with the disastrous results we see in our country today — homelessness, incarceration, the disintegration of families, and death. PRESIDENTIAL ACTION * Work with legislators to change “must be a danger to self or others” criteria. * Work with legislators to change involuntary commitment criteria, alleviating the subjective nature of “gravely disabled” and redefining it in objective terms based on scientific medical need for treatment. Psychosis, like a stroke, is a traumatic brain injury and needs immediate treatment for the best outcome.
EXTENDED LIST OF SMI NEEDS
This list represents brainstorming ideas of advocates from across the country. They’re individuals, families, and professionals who are living/working with SMI. They have in-the-trenches experience. The list presents a partial picture of the depth and breadth of SMI issues that need to be addressed.
1. RECLASSIFY SERIOUS MENTAL ILLNESS (SMI) FROM A BEHAVIORAL CONDITION TO WHAT IT IS, A NEUROLOGICAL MEDICAL CONDITION.
2.REFORM THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
Present patients and families with a social worker to support the family unit throughout the care process, including medication and psychiatric treatment.
Require mandatory HIPAA training for everyone in the medical profession and mandate a test on proven knowledge.
Develop a federal program for the administration of an advance directive (PAD) which includes a universal release of information and designates an agent if a patient’s capacity is lost.
3. REPEAL MEDICAID’S INSTITUTES FOR MENTAL DISEASE EXCLUSION (IMD)
4. PROVIDE A FULL CONTINUUM OF CARE
Provide inpatient care (IMD waivers), outpatient care (i.e., AOT, Clubhouses), and housing ( a full array from locked stabilization to unlocked intensive, medium intensive, peer run, PSH, asylum).
Require a psychiatric standard of care for various SMI diagnoses like other medical specialties.
Require prescriptions based on need not ROI for the insurance industry
Remove ER’s as entry for mental illness hospitalization. The ER process and its chaotic environment aren’t conducive to the well-being of SMI patients.
5.DECRIMINALIZE SERIOUS MENTAL ILLNESS
Eliminate solitary confinement in jails and prisons.
Support nationwide civil mental health courts and expand criminal ones that are already established to keep SMI out of jails and prisons.
Establish mental health courts on a federal level, and coordinate federal courts and state-run mental illness facilities.
Move crimes that SMI commit in the federal system into state courts.
Mandate a way for families to provide medical history to jail/prison doctors to inform treatment.
Fund a digitized system for medical records in counties/hospitals to jails so information can be transferred immediately upon arrest and incarceration.
Provide uniform psychiatric screening of the incarcerated.
Use standardized protocols for medication of SMI prisoners.
Require strict limits on waiting for trial time.
6. PAY ATTENTION TO SUPPORTIVE HOUSING
Provide 24/7 supervised housing for those who cannot live independently.
Provide defined levels of support built around a person’s needs, especially long-term care.
Clarify Olmstead for SMI. Lease restrictive care isn’t always least expensive or best.
Examine, don’t ignore, a person’s ability to handle and benefit from a less restrictive setting.
7. REVAMP INVOLUNTARY TREATMENT
* Use lack of insight (anosognosia) and grave disability as criteria for determining involuntary treatment.
Establish a federal standardized “need for treatment” involuntary commitment law.
Base restrictive settings on actual abilities, not wishful thinking or one-track plans.
8. INCLUDE EDUCATION
Require mandatory, institutionalized education about SMI for judges, sheriffs, attorneys, district attorneys, law enforcement, and first responders.
Require units of SMI education for educators — preschool through university.
Revamp Crisis Intervention Training and expand training to all counties.
Provide a health proxy form for college students to allow them to release medical information and name who can take care of them in a crisis.
Hold universities accountable and required to connect students to crisis intervention, especially during medical leave.
9. GIVE INCENTIVES
Incentivize the expansion of medical schools to graduate more psychiatrists, child psychiatrists, internists with psychiatry specialties, psychiatric nurse practitioners and physician assistants.
Allow loan forgiveness for providers treating SMI.
Give incentives for rural psychiatrists.
Incentivize more long-term treatment/stabilization of SMI.
Give incentives to psychiatrists to accept health insurance, especially Medicaid.
10. EXPAND ASSISTED OUT-PATIENT TREATMENT (AOT)
Federally clarify AOT and create a federal model for AOT law
Offer AOT immediately to everyone upon diagnosis.
11. IMPROVE HOSPITALS
Build regional federal hospital for patients who cannot be treated in their home state’s hospitals because of lack of beds.
Improve reimbursements to hospitals which lose revenue on SMI patients.
End hospital discrimination against SMI “violent” patients and those “difficult to discharge.”
12. INCREASE RESEARCH AND EPIDEMIOLOGY
Fund NIMH research specifically for SMI.
Establish a Disability Advocacy Program for legal services for SMI when counties/states fail to provide long-term support services or when insurance/managed care and Medicaid fail to cover/pay for long-term supported services and treatment.
Pursue better national epidemiology studies for people with SMI.
Establish a federal law that requires states to track each SMI diagnosis with bad outcomes like death, homelessness, and incarceration.
13. REVISIT PARITY
Clarify parity for SMI and include Medicaid and Medicare in parity law.
Enforce violations against parity law.
14. ADDRESS SOCIAL SECURITY AND DISABILITY INCOME ISSUES
Change the way social security income for the disabled is taken by states when a patient is admitted to state operated mental health institutions, residential care facilities, and hospitals.
Increase disability income to a level where a person can survive and maintain reasonable housing.
16. CREATE PSYCHIATRIC CAMPUSES
Build psychiatric campuses with multiple levels of care, supportive housing from most restrictive to least restrictive, and separate independent living apartments.
Provide on-campus coffee shops, gyms, recreational facilities, and gardens where people with SMI could work with support as needed.
Provide substance abuse treatment services, AA or NA meetings.
In the aftermath of two traumatic mass shootings, the president re-invokes a horrid, distorted falsehood about the mentally ill.
And there it is: history’s defining damnation of sufferers of incurable damage to the brain, distilled into a three-word phrase of transcendent ugliness and stunted understanding.
The phrase was uttered on Monday. It was uttered to identify the provenance of the weekend’s massacres by shooters using legally purchased high-capacity semi-automatic weapons toward their collective harvest of 31 people dead and some 50 wounded.
The phrase was uttered by the President of the United States. It left stains, stains which, in moral and intellectual terms, replicated the stains of blood shed by the shooters’ victims.
Blaming “mentally ill monsters” (or “nut jobs,” or “wackos,” or “lunatics”) for such carnage is a morally repugnant, if time-tested device for shifting the public’s passion for safety away from gun control and toward the presumed demons in our midst. The president could not have been more transparent in exploiting the device. “Mental illness and hatred pulls [sic] the trigger, not the gun,” he instructed us, going on to label one of the shooters as “another twisted monster.”
In fact, it is a settled truth in psychiatric research that victims of brain afflictions are no more prone to violence than the general population. The prominent advocate Dj Jaffe makes an important stipulation: that the untreated mentally ill—those not stabilized by antipsychotic medications—can be more likely to cause harm to themselves or others. Still, implying that mental illness itself equates to degenerate aggression serves only to further isolate and punish the most helpless members of our society; to herd them back toward the dark corners and confinements of “insane asylum” days.
And herein lies the “intellectual” stain that President Trump’s words help spread: most people—like the president himself—do not understand mental illness: what it means, how it occurs, how it differentiates, why its victims behave as they do, and how even its most abject sufferers can be aided, often stabilized, by medications and therapy. In this vacuum of understanding, people tend to substitute prejudice, false science, myth, and hostility toward “crazy people.”
“Serious” mental illness—the kind in question here—is rare and unique. And incurable. Unlike alcoholism or anger or depression, serious mental illness is rooted in genetic flaws of the brain. Its various names include schizophrenia, schizoaffective disorder, bipolar disorder—similar yet not interchangeable conditions. It results in a loss of reason and rational control; hallucinations and the hearing of voices; alienation from family and friends; and, yes, sometimes—rarely—violence.
My wife and I have educated ourselves about serious mental illness because we’ve had to. It invaded our family several years ago, causing the suicide of a beloved son. Unfortunately, this is the painful route to understanding for most people: a loved one is stricken.
The costs of this cluelessness describe a cone of destruction that widens from the stricken individual through society.
The cone draws in and ravages parents and siblings of the stricken. It can cripple the finances of families without adequate insurance to cover treatment and medications. It drains human capital from the workforce, and thus economic revenue. It reduces the budgets of hospitals that can’t get reimbursement for their mentally ill patients. It overburdens police, whose lack of training and, sometimes, self-restraint, can result in death by gunshot of unarmed people in psychosis. It coarsens our criminal-justice system: think of schizophrenic adolescents hustled into jail by untrained or uncaring judges, where they await trial—often for weeks and months—while their unmedicated psychosis deepens. Think of solitary confinement. Think of a brain-afflicted child, perhaps your own (as countless parents must) ensorcelled in a cell, abused by fellow inmates and guards, with no end in sight, no comprehension. No hope.
Now think about “mentally ill monsters.”
Mentally ill monsters are not the source of our current crisis of public massacres. The monster is the gun: too many guns, with too little restraint and oversight regarding purchase. To his credit, President Trump gave lip service to keeping guns away from those “who pose a grave risk to public safety,” and to strengthening gun laws generally.
But leave the gun issue aside. Part of any president’s duty—a foundation of his “bully pulpit”—is to educate his fellow citizens on matters of complexity and urgent public import. The nature of serious mental illness, and the reclamation of its victims, comprise one such matter. The president could make a great, galvanizing contribution to ending the centuries-old oppression of “crazy people.” He could lead us in that direction. He could educate us. But first he must educate himself.