By Robert Landauer – editorial columnist for The Oregonian, September 6, 1996. Not available elsewhere online.
A thirtyish woman stops paying her bills, appears dirty and disheveled, no longer talks to neighbors, sends family away when they come to the door and is described as delusional by her apartment manager.
She definitely needs help, says Barry S. Kast, administrator of Oregon’s Mental Health and Developmental Disabilities Services Division. But she rejects it.
It can’t be proved that she is gravely unable to care for herself. “But as night follows day,” says Kast, invoking Shakespeare, “we know that she will become gravely unable.”
Yet that forecast, validated by earlier episodes, is insufficient to commit her for treatment.
This woman later was taken to a Portland hospital in an acute stage of mental illness. Doctors felt she urgently needed longer hospitalization, but a judge refused to commit her because the treatment had eased the acute symptoms. The court released her — in hospital gown and slippers.
Kast describes another incident. A young man is pounding on a Portland department store’s windows and talking to the mannequins with rage. The public sees him as crazy, frightening. The county staff members see him as someone who doesn’t meet commitment criteria for dangerousness to self or others.
Then there is the Portland suburbanite, a paranoid schizophrenic, who had gone off his medications and started displaying bizarre behavior. He was arrested for an act of public disorder.
His family wanted him to commit himself for treatment. He saw no need for help. The well-to-do family had three doctors examine him. All testified that he should be hospitalized.
The judge released him. Even though the man’s public behavior was disorderly and even repugnant, there was no convincing evidence that he was dangerous or couldn’t minimally care for himself.
From the families’ point of view, each decision by the judges was an outrage: Their sons and daughters are mentally ill. As they lose touch with reality, becoming terrified, angry and isolated, they do not see themselves as ill, so they spurn medications, become suspicious of doctors and caseworkers and reject treatments. These are not knowing decisions, aware of consequences.
These cases are typical. That exposes the chasm that has opened between public perception and what the law allows.
Like a long-running road show, the same issues replay all across the country. Legal, ethical and financial pressures push states to treat the mentally disordered in settings that least restrict their liberties. But releasing them from institutions may lead to no treatment at all.
Indeed, doctors, caseworkers and police routinely encounter two problems with the mentally ill. The first is that there often is not a single empty mental -health bed in which to place a person suffering an acute attack. So on any given night, about 7 percent of those in Oregon jails are mentally ill.
The second difficulty is that it can be almost impossible to commit and treat a person who obviously needs help. Americans hate the idea of railroading anyone into involuntary detention. So, with U.S. Supreme Court blessing, the state must prove that the mentally ill persons — defended by state-paid lawyers and psychiatrists — are dangerous or so unable to care for themselves that life itself might be threatened.
Either one can be tough to prove. In fact, mental -health workers often remark that the patient died with his rights on.
When we go to court, we assume there are opposing interests. This is a distortion, even a delusion, in mental -health hearings. Everyone there wants the best for the afflicted person. That can be devilishly difficult to figure out — especially when the only real-life alternatives might be lockup treatment or unstructured exile to a psychiatric ghetto under a bridge.
This is a pathetic way to deal with sad issues. Even laymen devoutly concerned with rights should understand that families and doctors do not widely conspire to railroad the mentally ill into medical dungeons for years.
Oregon must find ways to help its 50,000-60,000 mentally ill before and during crises. Now, we get so entangled in law designed to protect the vulnerable ill that we deny them the freedom that can come with treatment.