Penetrating the Gloom

By Robert Landauer – editorial columnist for The Oregonian, October 19, 1996. Not available elsewhere online.

Rays of hope cut through despair shrouding Oregon’s 50,000-60,000 severely mentally ill persons

“We have a daughter, now 45 years old, who has had schizophrenia for over 20 years. She has always refused medication or any consultation with any doctor.”

So began one of many responses that followed recent columns about Oregon’s severely and persistently mentally ill population. The letters were strikingly like coins. Heads showed pictures of families’ tragedies, desperation and exhaustion. Tails was the stamp of these misfortunes on communities’ medical, police, court and jail systems.

“Unfortunately, with the laws the way they are,” the father continued, “we have never found a means to force her into a medication program. She could profit very much from some of the new medications.”

Eventually neighbors or the parents will have to call the police “during one of her very bad psychotic periods,” he predicted, so that she might be forced into a medication regimen. Police may release her after a day or so, though, because they cannot show that poses a severe threat to herself or to anyone else.

“Thus one who could profit much from medical assistance will probably become worse and eventually be unable to care for herself at all.”

Families and communities struggle with how to help people who have lost touch with reality and may be unable to make informed decisions for themselves. Police and judges cannot put mentally ill persons in secure lockups — psychiatric wards — unless they have committed a crime or are clearly dangerous to themselves or others. So we honor a legal standard that denies medical help to people when they need it most.

Families, in turn, ponder how to protect their children from doing things they would not wish to do. Patricia Backlar, the Oregon Health Sciences University and Portland State University ethicist whom President Clinton recently appointed to the National Bioethics Advisory Commission, elaborates:

“Many people with schizophrenia don’t want to do these rampages; they get no pleasure out of them; they fear doing them again, yet they are not necessarily able to prevent themselves from becoming psychotic again.”

They resist taking medications because they believe they are not ill, because the medication might be ineffective or have distressing side effects, or because they view medications as parts of plots to harm them.

No cure-alls for mental illness have been fashioned. Yet small but important medical, legal and social-service advances can reduce patients’ and families’ distress and ease communities’ burdens. Some examples:

* The Multnomah County Alliance for the Mentally Ill honored the Portland Police Bureau Tuesday for its creative, courageous and compassionate advances in dealing with mentally ill persons during crises. The Crisis Intervention Team program, one of two in the nation, has trained 91 officers.

* New medications are expected very soon that may not produce the severe side effects that some patients experience with older medications. As side effects ease, more patients may be willing to take medications.

* Advance directives for psychiatric treatment approved by the 1993 Oregon Legislature are available. People with mental illnesses can make informed decisions when they have the capacity to do so about what treatment they consent to be given when they lose touch with reality during psychotic episodes. They can agree in advance to be held in a mental -health treatment center and provide details, such as what medications work for them and don’t work for them, said Backlar. Also, they can name a surrogate who knows their wishes to make proxy decisions when they lose the capacity for judgment regarding the issue at hand.

These instruments can greatly aid early intervention and prevention.

* More sophisticated outreach services offer new glimmers of hope. The early, street-level interventions of Project Respond in Portland can keep mentally ill persons living in the community for $4,000 a year of agency costs rather than in state institutions for more than $75,000 a year.

And in Eugene, says Backlar, Laurel Hill Center’s services “are as good as it gets anywhere.” The outreach extends right into people’s homes and apartments and helps the mentally ill to help themselves through vocational rehabilitation and job placement

* Outpatient commitment. More on this after a Nov. 14-15 workshop sponsored by OHSU, PSU, medical groups and the state.