On Getting Into Club Mad

Posted by WiredSisters on May 28th, 2014 filed in Bipolar Disorder, Guest Blogger, Health and Medicine

I’m a lawyer. I have taken courses in abnormal psychology. I have taught (for many years) courses on Professional Standards for Mental Health Workers, a required course for psychology majors in the school in question. I try to keep up with the field. And I’ve had a lot of crazy clients and a couple of crazy colleagues. I’m a member of the local bar association’s Committee on Mental Health and the Law, which doesn’t meet nearly often enough. I guess those are my credentials to talk about mental health.

Does anyone out there remember Snake Pit? It was a 1948 movie, based on a semi-autobiographical 1946 book, about a woman’s stay in a mental hospital. It depicted, in well-researched detail, both the upsides and the downsides of the institution. Then, in 1967, came Titicut Follies, a documentary directed by lawyer-turned-director Fred Wiseman, about the abuses committed against the patients at Bridgewater, a state mental hospital in Massachusetts. The state managed to restrict the display of the film by arguing that it violated the privacy and dignity of patients. Over much of this same period, One Flew Over the Cuckoo’s Nest was written by Ken Kesey in 1959, published as a book in 1962, and released as a film in 1975.

During this same period, social science studies of mental hospitals and their patients (such as Irving Goffman’s Asylum) also looked at how such institutions, and their staff, controlled their patients, and with what purpose. One such study (sorry, couldn’t find it on short notice) hypothesized that middle-aged working-class women sometimes used a mental hospitalization as a “vacation” from their domestic duties.

Monty Python’s Flying Circus, aired between 1969 and 1974, included at least one skit set in ‘St Nathan’s Hospital For Young, Attractive Girls Who Aren’t Particularly Ill’. And then there’s McLean Hospital, in the leafy luxury of the Boston suburbs. When I was in college, several people I knew, including my then-boyfriend, spent some time there. It also functioned as a kind of artists’ colony for a succession of writers from Robert Lowell to Sylvia Plath, and a stay there came to be considered almost the equivalent of a MFA degree. The locals sometimes called it “Club Mad.”

In short, mental hospitals came to be seen as either prisons for the poor or luxury hotels for celebrities and the rich. The latter function is now pretty much filled by substance abuse rehabilitation facilities like the Betty Ford Hospital, or Hazelden. The Supreme Court, however, took a large bite out of the former function in the O’Connor v. Donaldson decision (422 U.S. 563 (1975)), which was issued while I was in law school, and in which one of my professors had been involved. In that decision, the Court held that “states cannot constitutionally confine, without more, a person who is not a danger to others or to himself.” That decision is popularly blamed for the increase in homelessness on the streets of most American cities.

All of this is prologue to what happens these days to people with mental illnesses and not much money. Pop quiz: name the two largest mental health facilities in the US. If by that one means the institutions which house the largest number of people with mental illnesses (no, it’s not the United States Congress), the answer is Cook County Jail (in Chicago) and Los Angeles County Jail. They trade first and second place regularly, but between them they hold literally thousands of crazies at any given moment.

Lexical digression: “Crazy,” as I generally use it, is a social term; all the stuff in DSM-V is clinical terminology; and “insane” is a legal term. It’s important not to mix them up. “Crazy,” whether as noun or adjective, means acting bizarrely or reacting excessively for no apparent reason. To some extent, of course, it is in the eye, or the subculture, of the beholder. The DSM stuff describes various symptoms which its compilers construe as indicators of mental aberration or illness. “Insane,” in most legal systems, means mentally aberrant to the point of not being legally responsible for one’s otherwise illegal or criminal actions.

Why do we care about craziness, mental illness, or insanity? If its effects are felt only in the privacy of the sufferer’s home, we mostly don’t. If I have obsessive-compulsive disorder, and it manifests only in having to organize the socks in my drawer every night before going to bed, I will probably never be diagnosed at all, much less treated. Unless I spend all night on my sock drawer and eventually become unable to function by day from lack of sleep. That’s the point at which it becomes enough of an issue, for me, to become an issue for the rest of the world, because I can no longer support or sustain myself without help from the outside world. If my parents or spouse pitch in at that point to care for me without having to call in the public authorities, it’s still not a Problem with a capital P. As long as they can keep on handling the problem without asking for help. Once they won’t or can’t manage it themselves, and the public authorities step in, it’s a Problem.

However, unless it rises to the level of endangering somebody, it won’t be a serious problem for the law. The law recognizes The Problem by defining the grounds for involuntary mental hospitalization: danger to self or others, or inability to provide for one’s own needs (this is pretty much standard throughout the US, since the Donaldson decision.) Involuntary hospitalization is supposed to be the legal solution to dangerous behavior or inability to care for oneself. The model is that the person gets hospitalized, evaluated, and treated until the treatment resolves the problem and the patient is no longer dangerous. Then she can be let out. That presumes that the hospital has the space and time to evaluate and treat the patient, which, all too often these days, it doesn’t. It also presumes that the treatment can resolve the problem so that the patient is no longer dangerous. Sometimes this works, sometimes it doesn’t. It also presumes that the solution, if there is one, is permanent, so that the problem won’t recur.

Digression: back in the pre-Donaldson days, the point of the laws governing involuntary commitment for mental illness was to prevent people from being locked up who didn’t need it, for behavior that didn’t warrant it. Like Mary Todd Lincoln, after her husband’s death, for instance. Like the One Flew Over the Cuckoo’s Nest cases. It was presumed that a commitment hearing would involve the patient and his or her advocates and family trying to keep her out of the loony bin, and the prosecutors and the proprietors of the bin, perhaps motivated by the prospect of hefty insurance payments, trying to get her committed. The patient’s family members might collaborate with or even initiate this process for various sinister and often financial reasons of their own. My mother, who volunteered in the local mental hospital when I was a kid, saw cases of this sort now and then, and was appropriately outraged at them, often to the point of working to undo them.

By the time I was old enough to be aware of the existence of the system and professionally trained to be able to deal with it, it was a whole different ball game. Most of the cases were initiated by the patient’s family members, probably after having spent months and years dealing with the patient calling the police on them for being in cahoots with the Mafia, stealing their valuables to sell for drugs, or destroying the furnishings and appliances of the house in the course of trying to find the gremlins who were spying on them for the FBI. And the people most interested in keeping the patient out of the system (with the possible exception of the patient herself) were the hospital staff and administration, who had no space for one more patient, no staff time for her treatment, and no funding to support her. I have been involved in some of these hearings. They mostly consist of the patient’s family telling horror stories, interrupted occasionally by the hospital’s attorney intoning “Yes, but is she dangerous to herself or others?” And mostly, of course, she wasn’t, and the hospitalization was denied.

Which brings us to psychoactive medication. It’s better than making a person spend her life in a padded cell babbling to the light fixture. It’s certainly better than restraints or shock treatment. But it isn’t a science, it’s an art. Some medications work on some, or even most, people, to relieve some problems. Some people can be helped by some medications. Some problems lend themselves to successful treatment in most people by some medications. But some problems can seldom or never be successfully treated; some medications don’t work on most people; some medications work for a while and then stop working; and some people can’t be helped by any medication at all. There is no medication that works on all cases of a particular mental health problem, and no problem that can be treated successfully in every patient. You get the idea. You can help some of the people some of the time with some medications. You can’t possibly help all of the people all of the time.

That’s without even dealing with side effects. We modern Americans are accustomed to a model of medical treatment in which the patient feels bad, takes a medication, and then feels better. This gives her a substantial incentive to take the medication, at least until she feels better (though often, she may stop then, even if the recommended course of medication requires more doses. The result may be the creation of a drug-resistant strain of whatever. So far, this has not been an issue with psychoactive drugs.) But how do you provide an incentive for compliance with treatment when the patient starts out feeling absolutely terrific (for instance, in the manic phase of bipolar disorder), takes the medication, and then feels terrible (or, at best, blah)? This is counterintuitive, even to those of us who do not suffer from bipolar disorder. For a person who does suffer from it, it’s downright absurd—crazy, in fact.

Other disincentives for compliance with treatment may include the financial cost of the medication, or the logistic difficulty of getting a prescription filled and refilled. For a patient who is indigent and has to resort to some public or charitable agency, these can be serious issues. You and I, who are presumably unburdened by mental illness, are no doubt accustomed to calling in a prescription over the phone, or having a doctor do it for us, and then stopping in at the pharmacy on the way home from work or while shopping for groceries, handing over the insurance and any cash for copay, and going on our way in fifteen minutes or less. At a public or charitable pharmacy, the same procedure may take an entire day, or even longer. One may or may not have a place to sit down while waiting. For a person dealing with homelessness, mental illness, physical infirmity, and poverty, it may be the last straw, the easiest burden to dump when everything gets too much to handle.

In short, the model of hospitalization/evaluation/treatment/recovery is hopelessly optimistic for the people who need it most. Crazy, in fact.

It is conceivable that a mental illness could cause behavior that violates the law without endangering anybody. Shoplifting, for instance. Or the various indications of hypersexuality. Or fraud resulting from delusions that one really is the President and thus entitled to take taxis without paying. Can a person engaging in this kind of behavior be found not guilty by reason of insanity? Sure. (Conceivably a person could enter a perfectly valid insanity plea to a parking ticket, or at least to a lot of parking tickets, though the court would probably not be receptive to the plea.)  It happens now and then. These days, it is often dealt with informally rather than by the full panoply of a jury trial, but that happens too.

Aside from such rare and marginal cases, any mental illness that doesn’t endanger anybody is a problem only for the person herself, the people who care about her, and the clinicians who try to help. The latter are supposedly guided by the standards of the DSM. You can google the DSM in its various (I through V) incarnations to see what practicioners in the field think of it. At best they take it with a grain of salt.

The problem is that many insurance companies take the DSM as gospel and won’t pay for the treatment of anything that isn’t listed there. This may result in a single patient, over a lifetime of attempted treatment, having a dismayingly varied list of diagnoses, as various therapists attempt to match the current set of symptoms with something the insurer will pay for. That’s only one difficult aspect of the relationship between mental health care providers and insurers, which is fraught in many ways. You can’t blame the insurance companies too much. They aren’t really sure that mental illnesses are real illnesses, or that the mechanisms used to treat them are real treatments or do any real good. Many clinicians are equally skeptical, but still, they work hard and deserve to be paid. The insurance companies prefer pharmaceutical treatment to “talk therapy,” since it fits better with the standard model of medical treatment these days: as indicated above, you feel bad, you take a pill, and then you feel better. It takes a lot less of the clinician’s time, and can be expected (however unrealistically) to have more immediate and clearer results than talk therapy. With talk therapy, the insurance companies often demand really detailed descriptions of the problem and the treatment, often more detailed than any ethical clinician is willing to provide within the bounds of confidentiality. As a result, an increasing proportion of clinicians who provide talk therapy are refusing to deal with insurance companies at all. The patient pays out of pocket, or goes elsewhere for pharmaceutical treatment that the insurance companies will pay for pretty much no question asked. Most psychoactive meds, BTW, are not prescribed by a psychologist or psychiatrist or any other medical professional with expertise in mental health. They are mostly prescribed by primary care providers—internists, gynecologists, pediatricians, and general practicioners.

None of this gets at what is really worrying most Americans about the mental health system these days, which consists of two problems:

1) How can we predict whether a person will go nuts and shoot people in time to prevent it? And

2) How can we keep dirty smelly people who talk to themselves about the NSA listening in to the fillings in their teeth from sitting next to me in the public library or asking me for money on the street?

Given the current state of our knowledge of the human mind, Question 1 has no infallible answer. Inevitably, we risk either locking up people who will never be dangerous (so far as we know, most people with mental illness are unlikely to become dangerous. They are far more likely to be victims of violent crimes than to commit them), or not locking up people who are dangerous. Actually, given the current state of our legal system, we are very likely to do both. But whenever a person with an obvious psychiatric problem shoots a bunch of totally innocent people, we quite naturally come to prefer locking up too many harmless crazies to letting one dangerous crazy roam the streets. Until, of course, we have to pay the costs of hospitalization and treatment. Then we all become civil libertarians.

As for Question 2, using the legal system or the mental health system as a means to control public hygiene and etiquette is even more dangerous than using it to prevent violent crime. However, there may be more, cheaper, and easier alternative places for the unwashed indigent to go than effective mental health treatments for everybody who needs them. We know a lot more about the effect of soap and water on dirt than about the effect of Clozaril on schizophrenia.

In sum, it would be easier to handle the problems of people with mental illnesses if the rest of us were really sane and logical. “Fascinating,” as Spock would say.



One Response to “On Getting Into Club Mad”

  1. Sappho Says:

    “During this same period, social science studies of mental hospitals and their patients (such as Irving Goffman’s Asylum) also looked at how such institutions, and their staff, controlled their patients, and with what purpose.”

    I took Abnormal Psychology from David Rosenhan, who conducted the famous “On being sane in insane places” experiment, in which sane pseudo-patients briefly feigned auditory hallucinations, which promptly ceased after admission, and had rather a hard time getting out of the hospital (it being 1973, before the Supreme Court case you mention, when it was easier to get into the psych ward and harder to get out than it now is).

    “There is no medication that works on all cases of a particular mental health problem, and no problem that can be treated successfully in every patient.”

    A very common experience in the support groups my husband runs is going through multiple medication changes on the way to finding the one (or often the combination, as many people wind up on a cocktail) that works; people in the support group who have found their medication or mix will encourage those not yet helped to hang in there and keep trying.

    “Other disincentives for compliance with treatment may include the financial cost of the medication, or the logistic difficulty of getting a prescription filled and refilled.”

    I’ve seen a lot of struggling with the doughnut hole, for people on Social Security disability. Sometimes people get tided over temporary gaps in coverage by free samples that psychiatrists have accumulated. And we have a phone number that we give out to anyone who’s short of both money and insurance that people can call for prescription assistance.

    “It is conceivable that a mental illness could cause behavior that violates the law without endangering anybody. Shoplifting, for instance.”

    I knew someone who, when manic, shoplifted a single sandal.

    “you take a pill, and then you feel better. It takes a lot less of the clinician’s time, and can be expected (however unrealistically) to have more immediate and clearer results than talk therapy.”

    Well, it’s definitely easier to turn around full blown mania quickly with a pill than with talk therapy (the patient isn’t listening to talk therapy until he or she is less manic).

    “1) How can we predict whether a person will go nuts and shoot people in time to prevent it? ”

    Inevitably, the number of people who show danger signs and don’t actually shoot someone will handily outnumber the ones you really need to stop (the same problem we have in stopping sane killers, such as terrorists). All we can hope for is that psychiatrists and first responders keep refining their methods with experience, and continue sometimes to get it wrong.