Columns 2009

There are few answers for the mentally ill on the streets

I applaud any and all efforts made to help people with substance abuse and mental illness get the assistance they need to be off the streets and safe. So I support the recent proposal to use involuntary commitments as a tool towards getting alcoholics and drug abusers into treatment.

But having spent a lifetime working with people with the dual diagnosis of mental illnesses and addictions, I have to wonder how much help will ever be enough for them.

I trained as a nurse in the late sixties.  It was a time when doors were being flung open on mental institutions and a new wave of thought ran through treatment programs. The idea was that with proper support and medication, most people with mental illnesses could live outside of a locked institution and perhaps even create a productive life for themselves.  Civil rights attorneys argued that being mentally ill should not be an automatic ticket to a life locked away from society unless the person could be proven to be an immediate danger to themselves or others.

Since those heady days, we’ve learned a lot more about what happens to this population when it is simply shown the door and wished good luck in future endeavors – because that’s pretty much what happened. All those community mental health centers that were supposed to be built to support this group as it attempted to assimilate into the general population never did materialize in numbers near enough to provide adequate care.

And the mentally ill proved to have ideas of their own about how they would live that often did not include medication or follow up visits to any clinic.  Once on the street, many discovered that alcohol and street drugs made them feel much better than the medication dispensed from pharmacies. For so long as they were not an immediate danger to themselves or others, it was argued they should be free to make these choices.

And so, forty years later, we find ourselves with a somewhat intractable problem and few viable options for resolving it. Involuntary commitment into substance abuse treatment will work for some. But for those who also suffer from mental illnesses, it’s not enough. Even sober, they continue to make poor choices and put themselves in dangerous situations. They continue to go through the revolving door at API. And we seem totally stymied about how to create a long lasting positive change in this population.

Am I arguing for the creation of those horrible institutions where the mentally ill were warehoused in conditions that most of us would not allow for our family pets? No, of course not. But I am arguing that the system we now have is so broken that there isn’t enough money to throw at it to fix it.  And for those families who live from day to day in thrall to the wildly varying vicissitudes of their mentally ill member, it often seems as though they can’t remember a life not dominated by the problem.

That wears families down quickly, even those that start out strong. Given how many mental illnesses don’t show up until the person is in their late teens or early twenties, many families are completed blindsided by its appearance and bewildered by the limited array of choices available to them in dealing with their loved one.

It’s one thing for a lawyer to go to court and argue that someone who only 48 hours before had been admitted to API is now, after two days of medication, doing fine so there is no need for that person to be kept in a locked facility. It’s another thing to be the family of that person who, nine times out of ten, will go off their medication with some immediacy, hit the streets and start the turmoil all over again.

We need to start somewhere in helping people living on the street – those with mental illnesses, those with substance abuse problems, and those who combine both problems into something that seems to defy our best efforts.  Forced detox might be one step. But if we don’t come up with a whole bunch of other steps and see that they are adequately funded and coordinated, the revolving door will keep revolving.