A ruling by the Vermont Supreme Court, in my home state, has decided in favor of a patient suffering from schizophrenia who does not want medication or treatment. It’s a supremely vexing question, but I think the court erred.
The rock has rolled downhill again. The Sisyphean slog toward rational mental healthcare once more has been flattened under the weight of judicial folly.
On Friday, November 15, the Vermont Supreme Court ruled in favor of a plaintiff suffering from years of diagnosed schizophrenia—a person [mark this word] with a history of episodic violence and aggression, and periods of catatonia—who had asked not to be medicated against his will.
The ruling means that this plaintiff has likely ingested his last medical stabilizer against psychotic episodes—the final internal barrier to hallucination, delusional thinking, disordered speech and movement; and, in rare cases, violence to themselves and/or others. (It’s also likely that he wrote his request while stabilized, an irony that I will examine later.)
According to the court decision itself, as reported in the Rutland (VT) Herald, this person’s propensity to violent and aggressive acts while in the grip of psychosis is not merely theoretical. He has committed such acts before.
The court’s wording: “Patient has a history of unpredictable violence and unprovoked aggression toward hospital and treatment facility staff, police and others.”
Given the annals of psychiatric case history, there is little reason to doubt that, when seized by psychosis in the future, he will do so again.
My own family’s experiences testify to this likelihood. Our younger son Kevin was diagnosed as schizophrenic in 2003. He rejected his antipsychotic medications in 2005, and in July of that year, a week before his 21 st birthday, Kevin hanged himself in the basement of our Middlebury home.
It’s essential to pause here and parse the meaning of “person.”
The man in question—the core person—is not inherently a criminal, just as life-affirming Kevin was not inherently suicidal. The authentic person is described as intelligent, a reader, a researcher of information. It is the incurable disease itself, which invaded the person’s brain and has rendered his life hellish since the age of 12, that bears responsibility for his aberrant impulses.
The basis for the court’s ruling seems to be an “advance directive” created and signed by the patient in 2017, in which he stated that he wanted no neuroleptics or antipsychotics, no psychiatric drugs, “no medications I do not desire at the time.” Advance directives are documents that state the signatory’s medical-care wishes in the event the writer has lost the capacity to make such decisions on his own.
I believe that the Vermont Supreme Court’s ruling in this case was misguided. I believe it poses risks to people who come in contact with the plaintiff (or more accurately, with his psychosis); risks to the plaintiff himself; and risks as a dangerous precedent, for the same general reasons.
I don’t write these words lightly. Severe mental illness is a uniquely accursed affliction that defeats good intentions and pits legitimate purposes against legitimate purposes, as in this case. No one wants to live in a society that withholds a person’s right to control her medical destiny.
But there is that stubborn word again: “person.” It’s revealing that the plaintiff wrote and signed his advance directive in 2017, a period in which he was in the care of the Brattleboro Retreat for a sixth time and was being administered the antipsychotic medication compound trifluoromethyl phenothiazine. Presumably he was in relative control of his thoughts and actions. If so, he was in (relative) control exactly because of the medication. This is the irony I promised earlier.
I write “relative” control because a frequent traveling companion of schizophrenia is anosognosia—a medical term for “lack of insight.” Anosognosia shows up in about half of all schizophrenia cases. Its effect is to convince the sufferer that everything is fine. There is no disease. And so, no need for medications and their often harsh side effects.
Ultimately, the Vermont Supreme Court decision was grounded in “rights”: the “right” of a citizen to be free from involuntary medical treatment if he so decides. But what if the decider is not the citizen but the disease itself? In my clearly non-judicial opinion, the “right” in such a case must default to the core person: the entity who will be among those harmed, perhaps fatally, by the disease’s “harm to self or others.”
Vermont, and the nation, need to drastically reconsider the balance of legitimate purposes in granting medical immunity to people who are incapable of judging that right in a rational way. The entire question of “rights” in this context is an artifact of overzealous liberal activism in the 1960’s. Vermont is a fairly liberal state, and I personally hold to liberal views. But this is not really a question of ideology. It is a question of common sense.
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.
You may have missed it, given the uncapped pipeline of news raging out of Washington, but on Friday, February 28, President Trump signed into law a Republican-backed measure to restore gun-owning rights to people afflicted with serious mental illness, such as schizophrenia. The rollback would relieve some 75 thousand mentally ill people from accountability to background checks.
Trump’s action struck down a congressional regulation spurred by President Obama as a response to the notorious 2012 massacre of 20 young schoolchildren in Newton, Connecticut. That particular butchery was carried out, via a (legally purchased) semiautomatic Bushmaster XM 15-E2S assault rifle, by the 20-year-old Adam Lanza in Newton, Connecticut. Lanza had begun that morning by putting four bullets into the head of his mother at their home with a (legally purchased) .22-caliber Savage MK II-F bolt action rifle. Then, carrying the Bushmaster and two (legally purchased) handguns, a Glock 20SF and a 9 mm Sig Sauer P226, Lanza climbed into the family car and drove off to the nearby Sandy Hook Elementary School. He used the Bushmaster to shoot his way through a locked front-entrance door, then stalked the corridors and classrooms, gunning down children and teachers in small random clusters. In addition to his tally of 6- and 7-year-olds, Lanza murdered the principal, the school psychologist, three teachers and a teacher’s aide, and wounded two teachers. At least two of the teachers had been shielding children with their bodies when the Bushmaster’s bullets struck them. The dead teachers included the school psychologist and a part-time behavioral therapist.
Lanza, who had methodically paused to reload in the course of his meandering spree, then withdrew the Glock and shot himself in the head as police closed in.
A search into voluminous police reports later revealed that the young man underwent consultation at the Yale Child Study Center as an adolescent, and had been prescribed an antidepressant. The files revealed no diagnosis of serious mental illness.
Obama’s measure had infuriated Republicans and the National Rifle Association from the outset. (Technically, the rule required the Social Security Administration to inform the FBI about disability insurance recipients with mental impairments—and who needed a third party to manage their benefits–effectively disqualifying them from buying guns.)
It was the Republican congressman Sam Johnson of Texas who introduced legislation to block the bill. (Around this same time, in late 2016, Johnson, in his role as chairman of the House Ways and Means Committee’s Subcommittee on Social Security, also released a plan that would drastically reduce that program’s benefits.)
All of which is by way of saying—brace yourself—that yet another of the most morally fraught public crises of our time, the question of powerful firearms in the hands of the mentally ill, has been distilled into ideology.
Let me acknowledge the two most formidable arguments posed by those who agree with the congressional GOPs who voted to roll back the rule.
One argument involves the impossibility of determining who, among the mentally ill, is a threat to commit deadly violence, and who is not. Homicidal schizophrenia is not predictable. Mental illness itself is not predictable. Sandy Hook was not predictable. (See Adam Lanza.) Therefore, the Obama rule was prejudicial, to the disadvantage of nonviolent people with serious mental illnesses. Or so one may persuasively argue.
The other argument restates the familiar Second Amendment case held by gun-rights advocates: restricting firearms possession by anyone is unconstitutional. Period.
Is there a logically airtight counter-argument to these positions? If there is, you won’t find it here. I am not by temperament an absolutist—not on any topic. Dammit. I kind of envy those who are, though I don’t much care to be around them. Absolutism, like carpet-bombing, gets rid of a lot of thorny impediments. It just ain’t my style.
And yet I believe that the new Trump law is wrong; an unnecessary risk to public safety, including the safety of people with eating and sleeping disorders; and an affront to those trying hard to invest the troubled American mental healthcare scene with clarity and moral purpose. I’ll explain, in my timorous, hanky-twisting way:
Schizophrenia is different. Guns are different. Each is different from its category on an order of magnitude that sets it apart from recourse to fixed ideas. Each poses a unique menace to safety, to the Self, to human life. When combined—when a firearm is made accessible to a schizophrenic person—these menaces increase in potency, even though any given afflicted gun-owner is statistically unlikely to commit violence.
Let’s take guns first. What is there left to say? Guns are instruments of killing. Increasingly, rationalizations aside, they are manufactured specifically to kill people. In this they are categorically different from (more intentionally lethal than) any other consumer product. The ideology of unconstrained firearms ownership has survived and hardened in the face of every interrogation of the Second Amendment’s ambiguities, every conceivable appeal to moral restraint, the safety of children in the household, common sense, self-evidently sensible safety measures. No argument I can make here will shift one grain of sand in that desolate desert. I might mention, for example, that my younger brother Jim, in the midst of a marital crisis in the 1970s, turned his hunting shotgun on himself and blew a hole in his head, leaving a widow and two young daughters. (Jim was untreated for any mental illness, and I do not take up his suicide in NO ONE CARES ABOUT CRAZY PEOPLE.) The responses to such tragedies from the gun-rights people are inscribed in the cosmos: Tough titty. These things happen. Shoulda seen a shrink. Law-abiding citizens’ rights. The only way to deter a suicidal man with a gun is with. . .
So let’s move on to schizophrenia.
Schizophrenia (along with its related afflictions such as bipolarity) is a brain disorder without parallel in human history. It is not a mood, reparable by therapy or good fortune. It is not an attitude, responsive to correction or coercion. It is not curable, though in many of the afflicted its symptoms may be controlled by antipsychotic medication. Such medication is resisted by a great many sufferers, whose judgment is crippled by the frequent companion scourge known as anosognosia, or the incapacity to understand that one is ill. The potential calamities enabled by anosognosia are self-evident. Thus, at least as it seems to me and thousands of others, schizophrenia victims require care and treatment that is different—more case-specific, more morally nuanced and always more undergirded with psychiatric insight—from treatment given to “normal” people in crises. This may mean, amidst hundreds of other considerations, keeping firearms out of the reach of certain mentally ill people—say, disability insurance recipients with mental impairments and who needed a third party to manage their benefits.
For understandable reasons—furthering fear and stigma, for instance—mental-illness advocates hesitate to emphasize or even admit the fact that psychosis and guns can combine to spread carnage. (This is one reason why the lessons of Sandy Hook have remained tragically muted.) Yet, as D.J. Jaffe, the outspoken director of the Mental Illness Policy Organization, has written: “. . .4 percent of those with mental illness are affected by serious ailments, such as schizophrenia or bipolar disorder, causing them to hallucinate or become delusional and psychotic. When these people go untreated they do have a higher incidence of violencethan the general population. http://mentalillnesspolicy.org/consequences/violence-statistics.html It’s an unpleasant truth that the mental health industry has encouraged politicians to ignore. Without recognizing the problem, policymakers won’t take steps to fix it.”
And so here we are, preparing to cope with one more feckless and gratuitous disruption of the arduous project to make society safer—not only for potential victims of people in violent psychosis, but for the mentally ill themselves.
I will not pretend to vouch absolutely for the nosological claims I have advanced here. No one can. That is due to schizophrenia’s properties as different.
But enough disclaiming. I believe that mixing guns and serious mental illness is an abomination.
Yesterday he vetoed a bill that would have limited the use of solitary confinement. (As one of the most demonstrably mind-destroying forms of punishment available, it should be banned altogether, everywhere.) Now he is restricting funds for the most abject members of society, the seriously mentally ill. This points not only to Christie’s particular brand of heartlessness, but also to the destructive myopia of too many public officials about the hellscape inhabited by “crazy people.”
Parents, siblings and friends are rejoicing over Wednesday’s passage in the House, by a 392-26 vote, of the seminal 21st Century Cures Act, a $6.3 billion bill to overhaul mental health care in America. The bill is expected to quickly pass the Senate and secure President Obama’s signature, transforming it into law.
Despite the euphoria and likely full passage, even its advocates acknowledge that the 21st Century Cures Act faces strong opposition from several influential sectors. The reliably progressive Senator Elizabeth Warren (D-MA) has criticized it for failing to constrain the “Big Pharma,” the notoriously profiteering multinational pharmaceutical industry, from profligate pricing and lax testing standards for protecting the safety of customers. On the other side of the spectrum, the conservative group Heritage Action for America,which has denounced the “gimmicky nature of the pay fors” in the Act—“the newly creating funding mechanism designed to bypass spending caps, or the overall level of spending.”
CongressmanMurphy pinpointed his satisfaction with the House vote while agreeing that it is far from a cure-all for serious mental illness in America: “We didn’t get everything we needed, but we needed everything we got.” The Congressman, who is a Navy veteran and a practicing psychologist, went to work on his Crisis Act in 2012, following the massacre of schoolchildren in Newton, Connecticut, by the 20-year-old Adam Lanza, who had murdered his mother before the shooting spree and who killed himself afterward.
I have devoted a couple of chapters to Congress’s history of ineptitude and indifference to mental illness in NO ONE CARES ABOUT CRAZY PEOPLE. In Chapter 13, “Debacle,” I examine the lingering social damage wrought by deinstitutionalization, the early-60s experiment in mass removal of patients from the nation’s flawed and overcrowded mental asylums without following through on guarantees that they would be cared for in a vast network of community-based centers operating without government oversight.
And finally, lest anyone imagine that the surviving mental and psychiatric hospitals have solved their problems, I offer the following short list of recent atrocities suffered by mental-hospital patients (all women, interestingly). I will add that my book takes its title from a string of horrific abuses, including at least one patient death by starvation (another woman, for whatever that may mean), that occurred at Milwaukee County Hospital in the years around 2010.
So: let us justly celebrate the House action on Wednesday in advancing the 21st Century Cures Act. But at the same time, let us not forget that much remains to be done—on the Act itself, and in our still-chaotic world of mental health care.