I encounter the mentally ill every day. I step over them on the sidewalks, I ignore their rantings, I look the other way when they rummage through the trash. I do this not because I'm hardhearted, but because I live in New York City, and there's really no other choice. Anyone living in any major urban area in America probably does the same.
During recent decades, we have literally dumped severely mentally ill people onto our streets, abandoning them to their disease and delusions. This is a great national shame, hidden in plain view. On July 22, President Bush's New Freedom Commission on Mental Health released a report that was an opportunity to address this neglect, but it, disgracefully, took a pass.
Most of the mentally ill roaming the streets are too sick to know they are sick. Roughly 50 percent of schizophrenics and those with bipolar disorder do not know they are mentally ill. Therefore, if seeking treatment is left as an entirely voluntary choice -- as it has been in recent decades -- these people will choose continued illness and misery.
Powerful forces oppose caring for the unwilling mentally ill: the American Civil Liberties Union, which maintains essentially that there is a right to be an untreated schizophrenic; the Scientologists, who hate psychiatry as a matter of faith; and "psychiatric survivors," the formerly mentally ill who were treated involuntarily and are ideologically committed to keeping it from happening to anyone else ever again.
The president's commission aped the language and concerns of this anti-involuntary treatment bloc, calling the mentally ill "consumers" and emphasizing the need for their participation in their "plans for recovery." That's fine, so long as the mentally ill people in question know they are ill.
The focus on "choice" fits with a long-running trend toward deinstitutionalization. In 1955, there were 559,000 people in state psychiatric hospitals. Today there are less than 50,000. If the situation in 1955 had held, adjusting for population growth, there would be more than 900,000 people in state hospitals today. Many of these people are out in their communities and doing fine, but others are living a nightmare on the streets or in jail.
There are some 450,000 homeless people in the United States, and about a third are mentally ill. Roughly 16 percent of prisoners in state and local jails have psychiatric illnesses. According to Dr. Fuller Torrey, president of the Treatment Advocacy Center: "The Los Angeles County jail, with 3,400 mentally ill prisoners, is de facto the largest psychiatric inpatient facility in the United States. New York's Rikers Island jail, with 2,800 mentally ill prisoners, is the second-largest."
Opponents of involuntary treatment maintain that the severely mentally ill would choose to get care if only mental health services were better. Nonsense. Says Torrey, "You could set up a suite in the local Hyatt with free coffee and cigarettes and these people would show up, but they still wouldn't take their treatment."
Opponents also argue that the "stigma" of mental illness keeps sick people from admitting that they need help. This is self-defeating nonsense. It is allowing mentally ill people to go untreated and roam the streets, free to do harm to themselves and others, that adds to the stigma of psychiatric disorders.
The severely mentally ill refuse treatment simply as part of their illness. The only answer is to treat them involuntarily, and there is a budding trend toward this solution in state laws. According to Sally Satel and Mary Zdanowicz, critics of the Bush commission's work, "Studies consistently show that the majority of patients initially treated without their consent agree with the decision when asked about it in retrospect."
There is no liberty in psychosis, and it is medication that offers mentally ill people true freedom. Unfortunately, the president's commission lacked the moral courage to make a stark statement to this effect and recommend policies in keeping with it. Meanwhile, on street corners all over America, very sick people are left to rot.