‘Mental Health Sham’ in State

The unforeseen and tragic consequences resulting from the de-institutionalization of mentally ill patients during the past decade is due primarily to the commendable but flawed belief that mentally ill people must have both liberty and security.

The mental health professionals are compelled to implement this noble abstraction under the operative jargon of treatment under the least restrictive setting rather than the best treatment possible for each patient. Accordingly, hospital confinement is always regarded as the last resort and California now has an upside-down proportion of its mentally ill in the community, mostly on the streets, rather than in hospitals.

Although ranking 13th in per capita spending for overall mental health, it ranks 49th in the proportion of a state’s mental health budget spent on hospitals.

Faced with the reality that up to half of the homeless are those whose mental illness is so serious that they would formerly have been institutionalized, libertarians still refuse to admit that they were unduly optimistic. Instead, they continue to insist that the policy would work, if only there were adequate funding for local community mental health services and shelters.

The blunt truth is that no amount of money can make treatment in the community a viable alternative to institutionalization for an indeterminate, but large, number of the severely and chronically mentally ill.

State hospitals are unique in design and location, with sufficient open space to afford the freedom and tranquility owed to ill people confined, sometimes for life, by court order. There are also remote and secure so as to assure safety to the public. Renovated motels and apartments or empty spaces in deteriorating shopping centers are not a suitable alternative.

The fundamental dilemma is that freedom for the mentally ill necessarily conflicts with the controlled supervision that many require, more for their own protection than that of others. The impaired judgment characteristic of mental illness, whatever the specific diagnosis, is likely to prevent the affected individuals from realizing that they are ill. As a consequence, they will not voluntarily seek treatment, nor can they be forced to accept it, unless they meet stringent legal standards for dangerousness and/or grave disability.

Accordingly, the Lanterman-Petris-Short Act of 1967, the statute that defines the means for achieving involuntary treatment, must be amended to incorporate a test of informed consent measurable by the patient’s peers and taking into account the entire historical course of the patient’s mental disorder. Furthermore, the burden of proof for the person seeking commitment, e.g., guardian or conservator, must be eased to the civil standard of preponderance of the evidence rather than the present criminal standard of beyond a reasonable doubt.

The revolving-door process that presently circulates mentally ill people from the streets to community treatment facilities, or for those less lucky to the jails, and then back to the streets again must be revamped. It is an utterly inhumane process for the patient always exacerbating his deteriorating condition, is ultra-hazardous to the public and a waste of taxpayers’ money.

Adequate community treatment facilities for people who aren’t troubled enough to require hospitalization are admittedly a vital link in the overall continuum of care required for this illness. More important, however, it is necessary to accept the grim reality that the most seriously ill cannot have both liberty and security. Therefore, we must return to the parens patriae doctrine of vesting solely in state government the solemn responsibility for the ultimate fate of these disenfranchised victims and any delegation to counties, cities or the private sector can only be nominal. The fragmented disparate and shoddy treatment delivered by counties thus far in the de-institutionalization process confirms the wisdom of this doctrine.

The present fixation for treatment in the least restrictive setting rather than the best treatment possible for each patient, coupled with gradual abdication of responsibility by the state government for their disenfranchised ill people in the real “ Mental Health Sham.” The illusory freedom achieved by the present policy comes at too high a cost to the patient’s welfare and at an intolerable risk and expense to the public.

LEO A. O’HEARN

Northridge