What To Do With The Mentally Ill?

Posted: July 03, 1986

The tragedy and pain of so many people that was revealed in the murder trial of Sylvia Seegrist brings into sharp focus once again the question: What should be done about the seriously mentally ill?

Pressure is mounting to incarcerate those who are judged to be mentally ill and "dangerous to others" until they are no longer a threat to society. Against that pressure is the stance that, with proper facilities and services, even the most severely disturbed mentally ill, can be absorbed safely in the community. A recently completed study in Philadelphia concludes that neither of these propositions provides a helpful answer by themselves.

It may be useful to try to dispel a few myths about the severely mentally ill and the "deinstitutionalization" program of state mental hospitals.

It has been established that diagnosed mentally ill persons proportionately are as prone to violence as those in the so-called normal population. If anything, they are more prone to be victims. They are, generally, of greater danger to themselves than to others.

There also is a widely held belief that the accelerated discharge program at state mental hospitals over the last 15 years has been a failure; that it is the primary cause of our current problems. The fact is that 85 percent of the discharged patients have been able to make social recoveries in the community with the help of families and community mental health centers and assorted social services.

Sure, there have been some dreadful mistakes made by state and local mental health authorities in the process of deinstitutionalization. The wholesale ''dumping" of hospital patients onto the local community with inadequate preparation, often determined by administrative and not by clinical considerations, is one example.

The lack of sufficient local professional services to meet individual needs of discharged patients is another example of bureaucratic insensitivity and incompetence. However, in the broadest sense, deinstitutionalization has

succeeded rather than failed for a larger number of former patients.

A principal concern therefore must be with the 15 percent of the discharged patients who are severely chronically mentally ill, unable to adjust in the community, and need more than the support services that include nursing homes, boarding houses, group and foster homes and the like. To add to the complexity, there is a growing group of "untreated" chronically mentally ill adults and alarmingly increasing numbers of younger people with symptoms of disabling chronic mental disorders who are not under treatment and should be.

Many do not seek help and refuse it when it is offered. The current legal involuntary commitment practices and procedures in Philadelphia make it difficult to place these patients promptly under psychiatric care.

It is generally agreed among knowledgeable mental health professionals that the majority of the severely chronically mentally ill population requires long-term psychiatric hospital and protective care and treatment. And it is precisely this group that has been trapped in a "Catch-22" predicament. Local programs are in no legal or financial position to provide long-term care and treatment.

The very wealthy who can afford to pay $500 or more a day receive treatment in specialized institutions. For those who cannot afford these expenditures, the state mental hospitals are, at present, their only viable resource.

A recent study by a special committee of the Mayor's Task Force on Homelessness assessed the problems of the severely chronically mentally ill in Philadelphia who are homeless. This is a small but significant number of persons (900 to 2,100) of the estimated 13,000 to 15,000 homeless persons in this area. The report's findings, however, throw considerable light on the nature of the overall needs of the total chronic mentally ill population, whose number is impossible to determine with any degree of accuracy.

The report cites four major defects in Philadelphia's mental health system:

* There is no effective citywide continuity of care program for the mentally ill. Many of the elements of a comprehensive program are in place, but there is no "string which ties them together." The mental health safety net is nonexistent. The report recommends creation of a permanent coordinating council of all the participants in the care system for joint mental health planning and action.

* There is no public emergency, reception, diagnostic evaluation and placement center to assure universal coverage and continuing professional responsibility for both acute and chronic mentally ill. At present, the city

funds 24-hour psychiatric emergency rooms in seven private hospitals and centers. As private institutions, they retain the right to admit or reject applications for service. Their resources are limited and difficulties increase as demand grows. The police and others are faced with constant frustration as they deal with these shortcomings.

The Philadelphia Office of Mental Health reports a significant increase in demand for emergency services. The majority of the city's hospitals will not admit "involuntary" mentally ill patients.

The report recommends that the city create and operate a public emergency reception and evaluation center comparable to the program which was discontinued when the Philadelphia General Hospital was closed in 1977.

* There is a critical need for first-class long-term psychiatric and protective services for the chronically mentally ill. Yet the state seems to be determined to curtail and even terminate the provision of its hospital services for the mentally ill. No one wants to go back to "warehousing" mentally sick people in overcrowded, understaffed state hospitals. But the reality is that state hospitals presently are the principal resource for the severely chronically mentally ill who need long-term mental health care. It is important that state mental hospitals be upgraded with professionally competent and caring personnel under creative leadership tied in with community mental health services.

A parallel need is for a network of protective long-term services for chronically mentally ill persons who do not need the full array of continuous psychiatric services.

* Finally, the mental health professions and the legal profession seem to be at loggerheads on the issue of involuntary commitments. A sizable segment of the seriously chronically mentally ill can be brought under care only through this legal process.

There is tension between those who feel that the law providing for due process and other civil rights of persons who may be placed involutarily in hospital custody is crucial, and those who feel that the judgment of professionals as to the needs of patients should predominate in any commitment proceedings. Since both groups are equally concerned with the welfare of the patients, a way must be found to assure that patients can get the care and treatment they need without violations of their civil rights.

Clearly, mental health professionals must learn to use professional opinion and judgment - just as public defenders and the courts must be willing to admit such opinions and judgments as valid evidence.

Conciliation between what are seen as "paternalistic" psychiatrists and ''militant" anti-commitment lawyers must be worked out at higher levels of professionalism. It is urgent that the mentally ill not be caught in a professional crossfire, while their fundamental needs remain unmet.

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