The Bishop and the Butterfly: Murder, Politics, and the End of the Jazz Age
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    Jared Loughner Is Insane (And We Just Noticed)

    By Doctor Cleveland on Fri, 05/27/2011 - 12:08pm | Politics, Social Justice

    So, Jared Loughner, who tried to murder Gabby Giffords, has been found unfit to stand trial because he is too mentally ill to insist his defense. Loughner, among other things, is apparently loudly insisting that Giffords is actually dead, because he succeeded in murdering her. That's pretty much the definition of "unable to assist in your defense" right there.

    I don't think anyone's surprised that Loughner is very ill, or that two independent psychiatrists would suggest a diagnosis of schizophrenia. But it's also clear that Loughner has been schizophrenic (and symptomatic) for a good long while, and he's just being given an initial diagnosis now. The American health system has left that important work, in this case, to the criminal justice system. Loughner had to shoot people before anyone noticed how much help he needed. That doesn't excuse him, but it sure as hell indicts the rest of us.

    Because we have no real public health system for people in their late teens and early twenties (the ages during which schizophrenia tends to emerge), we don't have anyone to diagnose, let alone treat, these ailments. And in the last thirty years we've cut back our commitment to mental health, "deinstitutionalizing" very, very ill people so they can wander the streets and suffer their symptoms.

    Jared Loughner was thrown into the care of institutions, like Pima County Community College, which have no resources or expertise in treating such profound and terrible illnesses. They knew something was wrong with him. They tried talking to him about it. And when the standard college counseling got no results, they expelled him for the safety of the other students. Every part of that process makes perfect sense, from their point of view, and I don't think they deserve even a shred of blame. College math teachers are not equipped to treat the seriously mentally ill. Nor should they be trained to do so. And Pima County Community College doesn't quite have the budget to do their normal job now; they can't afford to take responsibility for severe mental health problems.

    The issue is that America as a whole does not take responsibility for the mentally ill. We turn mental health into a game of hot potato, seeing who will step up and pay for the expensive care and treatment patients need and take responsibility for the patient actually complying with treatment. Will the college do it? Are you still on your parents' insurance, which may or may not have coverage for this kind of thing? In this case, the hot potato landed with the court system, now that the damage is done. The criminal justice system gets to care for the mentally ill because it's the one system that the mentally ill can't simply fail their way out of because of their symptoms. This country is full of very sick people who could actually be helped if anyone would actually help them, but those people are left either to the prisons or the streets.

    Do you know what's really not effective for dealing with major mental health issues? An employer-based insurance system. The mentally ill often have trouble holding onto jobs, and often have trouble accepting treatment until they've faced serious consequences. There are people who have been prescribed meds and don't take them, because they claim to be doing fine, and then they lose their jobs. But once they face an event that might persuade them to take their medication, there is no medication, because when the patient lost the job the patient lost the insurance. And preaching about individual responsibility to stay healthy, when we're talking about major mental illness, is laughably cruel. The nature of the illness is that the ill person is not fully responsible. Someone else needs to step up and make sure they get help. In our patchwork health system, the mentally ill are always someone else's problem; only when they commit a felony are they understood as everybody's problem.

    Jared Loughner walked around with full-blown schizophrenia for years. There are plenty of other people walking around with his symptoms right now, untreated, drifting between convenience stores and parking lots and subway cars, nobody's problem but their own. And unless they hurt someone, they'll stay out there in the agonies of their own madness until they die. In our current system, that is considered the happy ending.

    Topics: 
    Politics
    Social Justice

    Comments

    Well argued.  I'd add two points.

    1) Deinstitutionalization is popular, or at least politically palatable because most Americans think of mental health facilities as some sort of Hell behind bars and stone walls.  We imagine that, for the most part, the people within want to get out.  That is sometimes even true.

    2) This is a related point -- until some one has been harmed or a crime has been committed, we are (I think correctly) skeptical about forcing mental health care onto people.  Jared Loughners are thankfully rare.  Eccentrics who might have a diagnosable and treatable condition (but who also might not want treatment) are not so rare.  There's a lot of potential abuse once you get into the business of other people's mental states.


    by Michael Maiello on Fri, 05/27/2011 - 12:53pm

    On point #2, this new New Yorker piece is one excellent article:

    God Knows Where I Am

    What should happen when patients reject their diagnosis?

    by Rachel Aviv May 30, 2011

    Unfortunately, it's only available to subscribers right now or for purchase.

    I will type out two paragraphs from my print copy that are very applicable (though the whole article is, pro and con). This follows the long discussion of use of the theory that lack of patient "insight" that they are mentally ill  is a reason to committ them to treatment against their will. (It is noted that nearly 1/2 those with psychotic illness deny they are mentally ill.):
    Yet the notion that denying an illness is proof of its existence is a dangerous one, since there are many valid reasons that people choose to refuse treatment, includeing the stigma of having a mental illness and the disabling side effects of medication. Elyn Saks, a professor of law, psychology, psychiatry, and the behavorial sciences at University of California, who has schizophrenia, said "Alleviating suffering is not a legitimate reason for taking away people's rights." When Saks was a law student at Yale, she was restrained and medicated against her wishes; she calls it one of the most degrading experiences of her life. She argues for greater use of advance directives, which function as psychiatry's version of the living will. In the past two decades, twenty-six states have passed laws that allow people to specify what kind of medical care they wish to receive if they lose theirr grasp on reality. Some directives include a "Ulysses contract"; just as Ulysses instructed he be bound to the mast of his ship so that he would not be lured by the Sirens, some people insist in advance that they be medicated or hospitalized even as they beg to be released. At the other extreme, people use directives to reject any future treatment at all.

    In her book "Refusing Care," Saks calls the method "self-paternalism," and argues that there are few other scenarios in which psychiatrists should forcibly impose treatment that intrudes on the privacy of people's own minds. A widely cited justification for compulsory treatment is the "thank-you theory," which assumes that patients will retroactively agree that intervention was in thier best interests. But only about half of patients who have been involuntarily hospitalized subsequently say that they needed treatment.  "We should not be in the business of choosing selves," Saks writes. It's impossible to determine whether a mental illness has altered someone's preferences, or whether that person has simply changed.

    I believe I saw Elyn Saks on a Charlie Rose show on topic in the past. (If not, it was someone very much like her.) For anyone nterested, that show is probably available on the net, as well as there's probably a website related to the advocacy in her book.

    BTW, the main story in the New Yorker article, of Linda Bishop, is very touching and tragic, is eloquently told, and forces the reader to consider both sides of the issue about forced treatment. It does also get into the history of de-institutionalization a bit. But the main point of the article if what many of us who have followed this problem know, which Doctor Cleveland's post does not address: that roughly 1/2 of the seriously mentally ill, do not want treatment and do not find a lot of the treatments available treatment satisfactory, even when offered the best that is available.


    by artappraiser on Fri, 05/27/2011 - 2:03pm

    Oh, also, for the opposing point of view to Saks, the article quotes the psychiatrist Edwin Fuller Torrey, who acts as an early advisor to National Alliance of Mental Illness (NAMI) created by family members who felt exclued from medical decisions made by their loved ones. His sister had shizophrenia. He says "to keep talking about civil liberty is illogical. Patients are anything but free if they're at the beck and call of their delusions." His own organization is the Treatment Advocacy Center in Arlington Virginia, which "has lobbied nineteen states to pass of strengthen outpatient committment laws, which require people to take medication after they've been discharged." In his work, he is a supporter of the patient "insight" theory (that whether they recognize and accept that they are mentailly ill is important in diagnosing mental illness) known as anosognosia. He thinks it is "the single largest reason why individuals with schizophrenia and bipolar do not take their medications."

    The whole article is about Linda Bishop's death from starvation at a farmhouse where she was secretly squatting after being released from treatment because she did not want to be put back anywhere into treatment. She was released because she knew how to act relatively sane if she needed to and refused to talk about mental illness or accept that she was mentally ill. (She participated in group sesions of various kinds but would never speak of mental illness.) She hid at the farmhouse after leaving, eating only a supply of apples she picked,  writing a diary (and reading a lot, she was a voracious self-educator,) which does show delusions, but also shows a strong will. (She knew she was starving, but just did not want to go anywhere else, was hoping things would magically change.) Her family was not notified she left the treatment facility, under privacy rules. So they did not know she was there doing that. Like a lot of NAMI members, they are angry about that, But that's about guilt. They think they could do something to save her. But could they? Maybe she didn't want to be saved by them....They had given up on her in the past at times, just let her be herself, by herself someone who couldn't always "get along."

    Coincidentally, while reading  a recent copy of the New York Review of Books, I noticed a big ad for a new book:

    Your Child Does NOT Have BiPolar Disorder;

    How Bad Science and Good Public Relattions Created the Diagnois

    by Stuart Kaplan, MD

    with three rave review quotes from three child psychiatrists at three different prestigious university centers. That reminded me of what a mess we have with big pharma pushing all manner of pyschotropic medications and with so many general care doctors, much less psychiatrists, accepting that so many need them. And that reminded me of how much supposed dementia of old age is often proved to be iatrogenic, caused by overmedication.

    Myself, I don't know what to think, but I sure do feel sorry for the severely mentally ill, precisely because I think most shrinks haven't a clue how to really help them and often make them more miserable. I think we are still in the dark ages on a lot of the more severe mental illnesses. Maybe that requires curtailing their civil liberties for society's sake, I am not decided.


    by artappraiser on Fri, 05/27/2011 - 2:36pm

    I'm not decided either.  The quote about somebody in the thrall of their delusions not having true civil liberties in the first place is somewhat compelling.  But I don't want to talk about Trump here.

    That's flip but, to one extent of another, we all have our delusions.  Sometimes, they even serve us well.  Then there's those pharma companies you point out, who have invented pills, it seems for every mental state from being tired to being distracted to being depressed to being too happy.  I don't want to be a Pfizer One Note.


    by Michael Maiello on Fri, 05/27/2011 - 3:26pm

    The poor will always be with us as will the schizophrenics.

    You can prescribe the pills to remove the voices from the patient's head and even calm the behavior Doc, but you cannot make them take the pills.

    I am more concerned that schizophrenics can purchase guns and oversized clips.

    Just as an aside, all but a handful of Senators voted for the fascistic Patriot Act extension.

    What was interesting to me was that Curly Rand Paul voted against the extension.

    But his reasoning was that the Act inhibits the purchase of guns. hahahahahahaha

    I give up!


    by Richard Day on Fri, 05/27/2011 - 3:19pm

    Geronimo famous quote:

    “I was no chief and never had been, but because I had been more deeply wronged than others, this honor was conferred upon me, and I resolved to prove worthy of the trust."

    "Late one afternoon when returning from town we were met by a few women and children who told us that Mexican troops from some other town had attacked our camp, killed all the warriors of the guard, captured all our ponies, secured our arms, destroyed our supplies, and killed many of our women and children… when all were counted, I found that my aged mother, my young wife, and my three small children were among the slain.”

    Excerpts from the biography "Geronimo: His own Story".

    http://www.gballard.net/photoshop.html?http%3A//www.gballard.net/photoshop/homeland_security_poster.html


    by Resistance on Fri, 05/27/2011 - 3:38pm

    Diagnosed schizophrenics generally can not legally purchase guns or clips of any size regardless if they are taking their pills (at least nowhere I've specifically checked the laws, but it's difficult to run down every jurisdiction and potential circumstance). However, untreated and undiagnosed Americans who may or may not be schizophrenic can buy 'em pretty much everywhere.

    The sad, simple fact is it appears nobody offered Loughner pills - or took any other approach - to "remove the voices" from his head. We likely should start by looking at this fact when seeking a way to better reduce the occurrence of armed schizophrenics. To me, in the wake of "the most sweeping healthcare overhaul in generations," if public health policy is such that crazy people remaining undiagnosed allows them access to firearms (with no change in sight), we should thank the '09 Democrats for enacting crummy public health policy, not Randy Paul.

    The most logical lesson to draw from Loughner is that increased public safety calls for increased focus on diagnosing and treating people with mental illness rather than obsessing on the existence of clips arbitrarily characterized as oversized. If Loughner had been limited solely by hardware availability to 10 shots in his gun, this would have still been 10 shots (and one gun) too many - the guy is frikkin insane.


    by kgb999 on Sat, 05/28/2011 - 12:48am

    You make good points as always.

    I do not wish to beat a dead horse but as O'Donnell pointed out several times on his program this crazy man was stopped as he attempted to change clips. Instead of 20 people left dead or wounded the number would have been ten.

    I never intimated that Curly Rand had anything to do with the incident.

    But the NRA certainly did!

    We have lost the battle over guns in this country.

    My problem with Paul is that one of the only good portions of the Patriot Act provided for a better tracing mechanism for following the purchase of arms on a data base.

    Paul and other wackos do not like data bases for guns. We have data bases for cars for chrissakes.

    Oh well.


    by Richard Day on Sat, 05/28/2011 - 9:55am

    KGB's heart is in the right place, but he doesn't know squat about federal gun laws, or how the system works aka gun purchasing.

    Diagnosed mentally ill people can buy guns.

    Adjudicated mentally ill people cannot. (....they can if they check the NO box on the ATF form -have you been adjudicated mentally defective ATF Form 4473, question F...!)

    A mentally ill person must be ADJUDICATED mentally ill. I have noted this fact before here without penetrating the apparent preconceived or naive notions of many thick skulled Dagbloggers. The Gun Lobby considers the right to guns is too important to be taken away by doctors alone, or merely by a doctor's diagnosis of mental illness.

    Adjudicated does not mean TREAT or DIAGNOSE. Your local college health clinic doctor cannot take away your 'right' to get a gun and/or a massacre clip, nor can any other medical doctor unless:

    A formal commitment of a person to a mental institution by a court, board, commission, or other lawful authority. Accordingly, persons with mental disorders who have voluntarily committed themselves to mental institutions and have not been judged by a government authority to be dangers to themselves or others, insane, or lacking mental capacity are not prohibited by federal law from possessing firearms.  This is true even if such mentally ill persons are believed to be dangers to themselves or others.


    by NCD on Sat, 05/28/2011 - 11:03am

    You seem to propose that because a single clinical diagnosis isn't sufficient to curtail rights, that diagnosis becomes irrelevant to preventing the mentally ill from accessing firearms. How do you imagine that the adjudication process could possibly proceed without a diagnosis? It simply can't. Without a robust support for mental health services, which should always start with diagnosis and a treatment plan, the adjudication process is somewhat moot.

    You also ignore the fact that every state I've ever checked (or been a licensed armed security guard in) also has ownership limitations based on mental sanity with additional specific requirements sometimes applying to municipalities. The question is far less cut-and-dried than you imply it to be here. In my experience, federal gun laws aren't generally the prevailing authority when it comes to real life implementation of firearm policy. The legal requirements go through at least one level of local before you even need to think about it. Which, again, is how it should be.

    Of course your local college health clinic doctor cannot "take away your 'right' [sic] to get a gun." That would be absurd. Any loss of rights should most certainly involve a formalized due process with reasonable avenue for appeals, etc. But a college health clinic doctor *can* refer a case to authorities. People are involuntarily committed for psych evaluations all the time. Adrian Lamo is a recent high-profile example.

    Far less people would be dying if anti-gun folks invested half the energy into making our systems work as they do into fighting against the constitution and refusing to explore any methodology for improving safety beyond blanket prohibition. Since prohibition is destined to lose every time (as it should), the dynamic leaves us with the NRA competing against the prohibitionists for who can most effectively prevent sane public policy from emerging.


    by kgb999 on Sat, 05/28/2011 - 2:37pm

    Adrian Lamo was sent to a hospital by police, was diagnosed with a mental illness, and his case has nothing to do with guns, or  who can buy guns.

    The unfortunate bottom line in America, is the system does work. The system as mandated by the NRA and its supporters. 

    The system: anyone can buy a gun if you have the money to pay for it. If you don't get one at a registered dealer, buy at a ATF form free gun show.


    by NCD on Sat, 05/28/2011 - 4:07pm

    A mentally ill person must be ADJUDICATED mentally ill. I have noted this fact before here without penetrating the apparent preconceived or naive notions of many thick skulled Dagbloggers.

    And it is very difficult in most states to get this done. It has to be proven in front of a judge that the person involved is a danger to themselves or others by a registered psychiatrist and the person involved can have their own psychiatrist there to counter any arguments.


    by cmaukonen on Sat, 05/28/2011 - 10:44pm

    But who would diagnose him, if he refuses treatment or even evaluation?  Should all prospective gun buyers have to submit to a mental health screening?  Somehow I think that would never fly with the crazies, who have a powerful lobby (the bipolar lobby gives equally to both parties!).


    by Michael Maiello on Sat, 05/28/2011 - 9:58am

    The authorities have the power to put a person into involuntary psych evaluation specifically for the purpose of allowing health professionals to determine if the individual is a danger to himself or others (usually 72 hours). It pops up from time to time in the media when someone with resources is unhappy at being subjected to the process. Once a person finds themselves in such a situation, refusing to cooperate generally results in a two-week hold.

    By the way, I am one of the "crazies". My point is that if all Americans had proper mental health care services (not to mention proper health care in general), we wouldn't need to make the point of diagnosis and treatment be a gun dealership. In a well-planned society, we'd also be diagnosing and treating folks with mental health issues who don't even want a gun.

    An approach to protecting against mass murder that consists exclusively of preventing a herd of random wandering untreated insane people from accessing any way to kill other folks seems poorly thought out to me.


    by kgb999 on Sat, 05/28/2011 - 2:56pm

    The American health system has left that important work, in this case, to the criminal justice system. Loughner had to shoot people before anyone noticed how much help he needed. That doesn't excuse him, but it sure as hell indicts the rest of us.

    Well some people noticed this trend. PBS Frontline did an expose back in 2005 called "The New Asylums"

    You can watch it online through the PBS website here:

    http://www.pbs.org/wgbh/pages/frontline/shows/asylums/

     


    by mageduley on Fri, 05/27/2011 - 7:21pm

    Sorry to chime in late. I was posting from a hotel room on a holiday weekend. My bad.

    I'm not interested in exonerating Loughner, as I said in the original post. Nor am I only interested in the mentally ill who might commit crimes if left untreated. I think leaving schizophrenics to suffer on the streets with their symptoms torturing them is a crime in itself.

    I'm not interested in forcing people to take their meds, or in institutionalizing people against their will. I acknowledge that there is an extremely blurry and complicated line there. But I am interested in people having easy access to diagnosis and treatment. And I am interested in those people having access to diagnosis and treatment after they get too sick to go to school or hold a job. To be frank, other indistrialized countries with different health systems tend not to have lots of extravagnatly symptomatic mentally-ill people on their subways, while we view that as routine. I think many, many more people could be helped, and many become productive citizens, if we had a real metal-health safety net.

    Can we afford that level of medical care as a society? I would answer with another question: how much are we paying, in real costs, by not having such a safety net?


    by Doctor Cleveland on Fri, 06/03/2011 - 3:30pm