“Whitaker clearly believes that schizophrenia should be treated without medication if at all possible. However he fails to focus any attention on the fact that on any given day in the United States half of all individuals with schizophrenia, or about one million people, are not being treated. This is a huge natural experiment to test his thesis. Many of these individuals are found in public shelters, sleeping under bridges, in jails, and in prisons. If Whitaker had spent more time in these settings observing the outcome of this natural experiment, instead of delivering lectures on his vision of the impending antipsychotic apocalypse, he would have written a very different book.”
As most of you know, E. Fuller Torrey is a psychiatrist, one of the strongest proponents of involuntary treatment, and a supporter of outpatient commitment — the process of mandating that individuals take psychiatric drugs for extended periods of time after being released from a hospital setting. In the quote above, he accuses Robert Whitaker of ignoring the plight of the homeless “mentally ill” who he believes would be better served by the modern mental health system and forced psychiatric drug treatment.
But before getting to Torrey’s argument, let’s first take a look at how those who are poor and homeless and suffering severe emotional distress are generally treated in the community. Often those who are suffering distress will be brought to a hospital setting by police or community members, or come in of their own accord voluntarily. Once hospitalized, they are almost invariably prescribed psychiatric drugs and often are prescribed antipsychotics.
They then follow one of two tracks. A large portion of this population returns to the streets within a week with a prescription or a short-term supply of these drugs. It is estimated that upwards of 50% of people who are prescribed antipsychotics stop taking them. There is no survey for homeless individuals but I would guess that the rate of “non-compliance” is significantly higher among them. Folks like E. Fuller Torrey would suggest that anosognosia — damage to the brain caused by mental illness leading to a lack of understanding that one is ill — is the primary cause of non-compliance. In essence, Torrey suggests that homeless people stop taking their meds because their illness makes them believe they don’t need them. He believes that if they only knew what was good for them, they would happily take these drugs.
However, there are numerous more understandable reasons why the homeless population stops taking these drugs. For one, the drugs all have serious side effects such as akathisia, dystonia, constipation, loss of libido, sedation, confusion and weight gain. The homeless population are also generally uninsured. Even if they are insured, they need to still come up with co-pays for these drugs when they have limited — or no — money. Finally, many come to disagree that taking routine doses of major tranquilizers will help them feel better.
In essence, this segment of homeless people who come to the hospital are started on potent psychiatric drugs and then quickly returned to the street — where they more than likely stop taking them. The stopping and starting of these powerful neuroleptics can lead to serious withdrawal symptoms that include severe anxiety, agitation, insomnia and psychosis that can be mistaken for underlying mental illness.
A percentage of the second group of homeless individuals who appear more severely emotionally distressed, with signs of severe psychosis and mania, will go before a judge in a civil commitment hearing and then will be involuntarily committed if they are deemed a danger to themselves or others. At this point, a decision can be made to force the homeless individual to take antipsychotics and mood stabilizers even if they don’t want to.
Forced compliance. The term is loaded with ethical issues and also presents a serious challenge to the constitutional right of individuals to choose how they live their lives as long as they are not harming others. These are not criminals, and yet we treat them worse than criminals by suggesting that they may in the future commit violence and therefore we must protect against them by keeping them in a permanent state of government sanctioned sedation.
Torrey makes the argument that he is acting humanely because the State is also protecting these individuals from themselves. But as evidence mounts that the long-term use of neuroleptics damages the brain and causes long-term health problems, the State is not actively protecting these individuals; it is complicit in causing these people long-term harm.
So: two avenues. One is the hospitalization merry-go-round in which homeless folks are started on strong drugs and then discharged to the street where the lion’s share stops taking them, leading to severe withdrawals.
The other avenue is being involuntarily committed for a prolonged period, and made to take neuroleptics if the individual will not take them willingly. Many states also have assisted outpatient treatment (AOT) laws, wherein an individual who is released from a hospital setting is usually forced to take a long-acting antipsychotic shot every week or two out in the community. This is something Torrey and his organization the Treatment Advocacy Center strongly promote.
On his website, Torrey makes some powerful arguments for assisted outpatient treatment.
He says that in studies AOT has reduced hospitalization, homelessness, incarceration, violence, “treatment noncompliance”, and caregiver stress. Let’s take him for his word that these statements are true.
But, let’s look at it this way; I bet I could get the same statistics if I physically restrained someone for months at a time. They wouldn’t be hospitalized, or incarcerated, or stress out the caregiver, because they would be restrained. I could also get the same results if I lobotomized these individuals. No need to worry about them being violent, because they have been surgically altered.
The act of long-term involuntary “treatment” is a form of chemical restraint that causes long-term brain damage. It is a severe threat to a person’s health and well-being. No matter what sort of “humane” results you get from AOT, it is completely negated by the implications of the State injuring people in the process.
Recently, Representative Tim Murphy introduced legislation that would sharply increase outpatient mandatory treatment, even for people who did not pose a threat to self or others.
As we move further into this Orwellian world, if this law passes, the State will be able to force drugs on individuals who may be suffering severely from emotional distress who present no inherent danger.
Every year 7.6 million people go through inpatient psychiatric hospitalization. A significant percentage of these folks are impoverished and homeless. For many of these individuals, they have experienced a high level of trauma due to their socio-economic condition. Instead of being served by the medical establishment, they are often traumatized further. We spend an enormous amount of money on the process of hospitalization. The average cost of each visit is about $5,700. The average length of stay is 8 days.
As a therapist working part time in an inpatient setting, I often joke about the cost of care with patients. When they find out their stay will cost many thousands of dollars I offer them a fantasy alternative; I say, “Hey, instead of coming here, we could have flown to Hawaii and stayed in a hotel, ate at gourmet restaurants and gone scuba diving and surfing all day.” They say, “Yeah, I bet I wouldn’t feel nearly as depressed if I did that.” It seems funny until you realize the massive misallocation of resources going towards paying for very expensive medical care instead of examining alternatives.
For the homeless population, my hope is that at some point we shift from spending such an enormous amount of money on emergency “care” and shunt more of those resources towards long-term assistance and services for the homeless. One of the best social programs to develop over the last two decades is the policy of “Housing First.” In this program, people who are homeless are offered an apartment first before addressing other concerns such as their mental health. Recently in Vancouver, this model was developed with good success. From an article in The Vancouver Sun,
“The Housing First philosophy rethinks the traditional model of addressing homelessness among people with mental illness, which first treated the illness, getting the patients ready to go into the community and then finding a place for them to live. Workers were often surprised and disappointed when the individuals were back in the hospital a few months later. “It was a revolving door,” Bradley said. “With Housing First we don’t make unrealistic demands on people.”
The new model provides them with a safe place to live and “after a while people begin to think about their substance-abuse issues and their mental-health problems when they don’t have to worry about being warm,” she said.”
I also think it is key that we turn away from medicalizing economic disadvantage and trauma. When someone is homeless, they are under an enormous amount of daily pressure to get enough food to eat, find a place to sleep at night, remain warm and dry in changing weather conditions and stay safe from people who would harm them on the streets. These are stressors that often lead to symptoms of severe distress such as depression, prolonged anxiety, and for some, spiraling symptoms of confusion and disorganized thoughts. For an in-depth look, Social worker Jack Carney gives a detailed explanation of the intertwining of poverty and people who are labeled with a mental illness. Activist and survivor advocate Will Hall also talks extensively about how those who are poor are more easily labeled mentally ill in this interview here.
Pathologizing these symptoms of distress and labeling them as an underlying untreatable illness further traumatizes many of these individuals. When they interact with health professionals, they are then offered “medications” to “treat” their illness. Instead of offering drugs to these folks, let’s offer what they really want, and need; access to better shelter, food and safety.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.