Involuntary commitment: it needs to be on the table

There is a great, blunt editorial by a man named Tom Zoellner published, “Reforms shouldn’t protect ‘Big Mental Health“. Though the issue is contentious in the mental health community and among those living with mental illness, Zoellner is absolutely right: involuntary commitment could save lives if it could be used more. This is both in more public situations (mass shooters with obvious symptoms and warning signs), and to save the lives of individuals who will otherwise kill themselves.

Charles Krauthammer is wrong about most things (he’s just a more intellectual-sounding Rush Limbaugh), but his experience as a psychiatrist and his work with mania is extensive and undeniable. Thus even in a column where most of his logic is shaky, like this work after Newtown, his point on mental illness is correct. Several social problems persist due to inadequate resources to treat those who suffer from psychosis, major depression, and mania. And if involuntary commitment was a possible option in more states and situations, some prominent shootings would likely not have happened. Jared Loughner and Seung-Hui Cho (the Virginia Tech shooter) had plenty of warning signs that teachers and friends recognized, but this didn’t filter up to the relevant authorities, and even then their hands can be tied by personal rights and privacy.

This is a balancing act, which is par for the course with mental health. People shouldn’t be locked away like in the days of the massive mental facilities, but they shouldn’t be left to rot when they reach the point where they can’t help themselves. People should be entitled to their privacy and autonomy, but there are times when an imminent threat exists, towards self-harm or harm of others. People should be treated with empathy, but should recognize that involuntary commitment can be an expression of that empathy. The heartless thing is to nothing when nothing is not the best option.

The opening point of the oped, that Republicans currently have a better understanding of what needs to be changed than Democrats do, is correct. Though given the Republican interest in reducing healthcare spending, that basic good idea shouldn’t mean they get the keys on overhauling the system. It points to a need to look at American mental health policy and figure out what works and what does not. Zoellner is right that services may have no track record of success. It’s true that services are redundant and mismanaged- I’ve volunteered at the county level and it’s a complete mess. Even experienced people are finding new groups and services year after year they didn’t know about. The uniting factor is that most of these places get government grants and subsidies; transparency about where this money goes and whether it is overlapping is key.

There are two ways to look at mental illness, where neither is full right nor wrong. One is that anyone with a diagnosis is incapable of living independently and needs to be locked up. The other is that someone with a diagnosis should be given full privacy and any suicidal or dangerous statements shouldn’t be communicated to relevant authorities. It’s key to see involuntary commitment as a tool that shouldn’t be used carelessly (like in the past), but it shouldn’t be ruled out entirely. There have been points where I was in a dangerous place, and the last thing I wanted was a culture of silence where nobody felt obligated to get me more direct help.

Coming out…as living with a mental illness

In a perfect follow-up to my earlier post on mental illness and stigma, Al Jazeera America has posted a lovely feature about Elyn Saks, a distinguished legal scholar who “came out” as schizophrenic in 2007.

I think her story helps demonstrate a parallel between combating stigma about mental illness and combating stigma about being LGBT. Friday’s celebrity news was dominated by Ellen Page coming out as lesbian. The more people that are open and public about their sexuality, the easier it becomes for those who are still tentative about coming out. Saks, by deciding to emerge as a genius academic living with a serious mental condition, sends a clear message. Having bipolar disorder, or schizophrenia, or major depression isn’t a personal failing, and it doesn’t guarantee a life of missed opportunity. There is power in her story, where she went ahead with her dreams despite pleas to choose a less ambitious career.

There are many traits that can isolate us- being LGBT, having a religious or political philosophy at odds with our family or community, and yes, living with mental illness. The reason I choose to live openly as a bipolar is that I’ve come to learn that I am not alone. There are other people like me, hundreds of thousands in the United States. When Saks and those like her talk about their experience in public, it helps to show that the struggle you are having is not unique.

And that it’s not something to ever be ashamed of.

 

Understanding what mental illness is and is not

I’ve been featured twice recently in articles about the Affordable Care Act and its impact on mental healthcare- first by the Peninsula Press, and subsequently by Generation Progress, which is an offshoot of the Center for American Progress think tank. This wasn’t by accident- I approached the author of the first article, Maya Horowitz, during a county meeting on mental health. What prompted me is the serious lack of literacy in regards to what people with mental disorders are like and the challenges they face. The ACA is a good legislative step by eliminating these disorders from disqualifying individuals from quality insurance, nevertheless there still is societal stigma.

A place I return to time and time again is the largest bipolar community on reddit.com. To some extent, in a non-medical sense I’m already somewhat of an expert. Living with bipolar disorder for almost nine years now, I see my own early struggles in new people that show up. In the pre-ACA era there was what I described to the Peninsula Press as “a climate of fear.” Consequently most people stayed in the closet, and avoided disclosing their status to co-workers. It was dangerous to let insurance companies know too much about your chronic condition, and embarrassing to disclose in a social setting.

Polls show that a third of Americans think prayer alone can overcome serious mental illness. People who openly talk about their struggles will inevitably get condescending suggestions to ditch their medication in favor of alternative remedies, yoga, or positive thinking. Many can improve their mood with exercise, sunlight, and improved diet; but scientifically it is clear that medication is the primary answer for people with severe major depression:

The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms, and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial. (2010 study, source)

The public by and large does not understand major depression, or bipolar disorder, or schizophrenia are, how they present, are diagnosed, and are treated. This lack of tangible knowledge leads to one of the most offensive aspects of mental health in America.

That the media and special interest groups are lumping all violent behavior with mental illness, and erasing any distinction between violent individuals, those with mental disorders, and violent individuals with mental disorders.

A large portion of mass shootings lead to a blame game, and mental illness is always brought up as a hand-wave answer for why such things happen. This is reinforced by scary news features, along with TV and film portrayals of sadistic, insane villains. However, the link to violence is an illusion. Terrible crimes are committed routinely by people with no trace of mental illness; the more blame lumped onto mental health, the less vigilant people are about other at-risk groups.

Indeed several mass shooters had serious mental issues, but they also had warning signs that should have been picked up on. More stigmatization keeps people from seeking treatment, and leading to risky and destructive behavior.

The reason I volunteered to go on the record is because there need to be more voices with experience, even though it’s always awkward to talk about mental illness in public. Anti-stigma campaigns are being formulated and launched- my county now has a unified campaign with quality materials. One way I look at the 21st century is how there are a shrinking number of acceptance prejudices. In many ways those with mental health are not treated with the same empathy and respect as others. They should.