We are all touched directly or indirectly by mental illness. Many commentators note unresolved issues and debatable policies within our mental health system. It is time as a society to rethink our approach to mental illness. This comment begins with an explanation of "public policy," followed by a very brief general history of our society's approach to mental illness, and concludes with 15 of the many questions that should be studied and debated.
Since the 1960s the U.S. has become gradually more open in acknowledging and discussing mental illness. Contemporary tragic circumstances surrounding individual and mass victims of violence, veteran and celebrity suicides, homelessness, and imprisonment of the mentally ill, among other situations, have heightened public awareness of mental illness.
Public policy consists of foundational concepts of the public good that underlie legal and governmental action. For example, public policy favors the orderly and safe flow of traffic, so we have traffic laws mandating speed and direction of flow. Sometimes public policy may be unstated. For example, city ordinances may prohibit feeding the homeless in parks under the stated public policy of public health and safety. The unstated public policy may be to move the homeless away from tourist and business areas for commercial reasons. Public policy addresses what characteristics of society are desirable.
Sometimes public policy concerning our society's approaches to mental illness is undisclosed. For example, is individual freedom promoted to make more palatable an unstated desire to reduce funding for treatment facilities? It is time for a comprehensive public policy discussion of mental illness with numerous constituencies' viewpoints being heard. This comment very briefly presents the major elements of this difficult but needed conversation. We can hope that positive reform and beneficial change will occur as society brings its best collective wisdom to this issue.
Historically, U.S. mental hospitals were developed as a humane alternative to imprisonment. However, abuses within these institutions and abuses of antipsychotic drugs produced a reaction. The legal standard moved from "need for treatment" without an individual's right to refuse treatment and medication to "least restrictive alternative" with an individual's right to refuse treatment and medication.
Simultaneously, the promise of community-based treatment reduced both funding and the number of beds per capita in state mental hospitals. Community-based treatment and group housing that maximized personal freedom was a laudable goal. However, it never had adequate funding at either the state or local level. Additionally, without sufficient legal grounds for mandatory confinement, mentally ill individuals were, for all practical purposes, released to the care of family members or to the streets.
Until a mentally ill person is imminently or overtly violent to themselves or others, family members have discovered that they are virtually powerless to request or require treatment of adults. Criminal activity by a mentally ill individual who does not meet a strict legal definition of insanity places her or him in jails or prisons not designed for effective treatment. All too often there is a revolving door from jail to the streets and back again.
Many commentators affirm that our current social approach to mental illness needs review and refinement. Furthermore, it must be noted and emphasized that only a very small percentage of mentally ill individuals act violently or in criminal ways. The media is drawn to the sensational in a manner that may distort public perceptions. My use of the phrase "the mentally ill" is not intended to stereotype or stigmatize. Like any population, this one is quite diverse. The following are 15 of many broad public policy questions and goals that must be discussed and addressed, in no particular order:
- There is a need to maximize individual freedom without malice, personal eccentricity, or political dissent becoming a basis for confinement. At the same time, an approach based solely upon the legal right of individual freedom may fail to provide for the unrecognized needs of that individual and the broader community in which this individual exists. Is society willing to say that there is an individual right to "mild psychosis" but not "psychopathic violence?" If medication takes the edge off psychotic symptoms, does it simultaneously reduce desirable personality traits such as creativity? This is hotly debated.
- There is a need to reconsider the role of the criminal justice system in situations involving a mentally ill individual. Have contemporary prisons become the functional equivalent of the old "asylums?" Are different approaches appropriate for violent and nonviolent offenders? How does the constitutional prohibition of "cruel and unusual punishment" apply to prison conditions faced by a mentally ill prisoner?
- There is a need to understand how mental illness is impacting both public and private budgets. What is the true cost of untreated mental illness as well as the cost of various contemporary treatment options? Do economic interests of the "mental health industry" unfairly favor the status quo? Where will the funding of programs and the care for those without financial resources come from? Economic resources for programs has long been a key issue.
- There is a need to allow contemporary medical, scientific, psychological, and even religious viewpoints to be heard. At the same time, it is well known that there are numerous schools of thought concerning the appropriate response to mental illness. Should society force mental illness treatment on the unwilling? Indeed, the very definition of mental illness and when intervention is appropriate needs discussion. Is a consensus possible?
- There is a need for close family members and friends of a mentally ill individual to be heard in specific situations. Is there an appropriate manner for family and friends to require mandatory evaluations and potential hospitalization? What individuals or entities, if any, should be authorized to intervene in specific situations? How may caregivers be provided relief from stress and abuse by a mentally ill family member that resides with them? Is the only option for overwhelmed caregivers to evict a mentally ill family member into a dangerous street culture?
- There is a need for housing and treatment options for mentally ill individuals. There is a need to discuss the concept of fundamental human rights that any just and decent society makes available to its members. Europe provides a model for this discussion. Do such fundamental rights exist and, if so, what are they? Does seeing a homeless mentally ill person on the street make society more callused to suffering? May society truly have seemingly throwaway people without seriously damaging itself?
- There is a need to destigmatize mental illness just as physical diseases such as cancer carry no personal stigma. It is well recognized that many individuals are fearful of seeking treatment due to employment, political, or social ramifications or fears of in any manner revealing their struggles even to close family and friends. Indeed, for example, there is a general societal aversion to even discussing death, much less self-inflicted death resulting from untreated depression or PTSD.
- How do we end the all-too-frequent and tragic, circular pattern of untreated mental illness, brief involuntary hospitalization until stabilization, release, homelessness, crime (misdemeanor or felony) and jail, followed by spotty treatment and release to begin the circle again? How may mandatory outpatient treatment be effectively enforced? Is society prepared to force otherwise free individuals to engage in treatment programs backed by a real threat of involuntary confinement?
- To what extent, if any, should access to weapons producing mass injuries be denied to a mentally unstable or mentally ill individual? How are weapons to be categorized since anything, even a rock, may become a weapon? How is stability and illness determined? Who makes such decisions? Is there a legally, politically, and socially acceptable answer to this question? Attempts to predict violence are difficult even for the most expert and experienced professionals. To what extent, consistent with having an open society, does society need to harden targets such as schools, malls, and public transportation facilities from actions by a violent mentally ill individual or terrorist?
- How shall society protect a mentally ill person from bullying (cyber or physical), violence, and exploitation? Do campaigns against domestic violence and sexual slavery provide any useful models?
- How shall society encourage innovative programs and innovative treatment of mental illness? Is there an objective manner to measure the medical effectiveness and duration of such innovations? Is there a way to mitigate the legal and economic risks of such experimentation?
- In any period of change or reform, how does society prevent the formation of a new mental health bureaucracy that merely replaces but does not improve a possibly discredited mental health bureaucracy?
- How should society balance the need for counseling and medical record confidentiality with the desirability of this information being shared on a "need to know" basis? Are contemporary legal standards adequate, or is revision appropriate?
- In any public policy conversation, how shall the mentally ill themselves be heard? What individuals or entities should speak on their behalf, if at all?
- May society trust any political or legislative solution to the difficult public policy questions associated with mental illness? Is governmental action part of the solution or part of the problem? Is this task appropriate for the nonprofit sector and its multiple entities?
Doubtless many topics of public policy conversation could be added to this brief list. The very best collective wisdom is required. Numerous conscientious commissions and committees have addressed aspects of mental illness. However, an overarching political, economic, and social consensus is required to meet these challenges and produce any lasting and meaningful reform.
May the treatment of mental illness become a priority? Leaders must lead. As a starting point, leaders from many segments of society must prioritize a climate of respectful and searching dialogue. Our many forms of media have the potential to encourage this. Let us hope that meaningful results occur for society, the families, and individuals impacted by the scourge of mental illness.