If you can choose, you have a chance?

Do homeless people with mental illnesses deserve supportive intervention or should their homelessness be respected as a rational choice?

Many of those with severe schizophrenia and bipolar disorder can't choose to accept services because they don’t even think they are ill. No amount of persuasion will convince someone to take medication if they think aliens are speaking to them through their teeth.

One homeless advocate who has been there sees the difference clearly - between his own situation and that of a man named Nathanial.

"I see a lot of myself in Nathaniel," says [Anthony Hamilton], whose illness is controlled with medication that's much more effective, and has fewer side effects, than what he and Nathaniel were both treated with years ago. "But one difference between us is that I knew something was wrong with me. Right now, Nathaniel doesn't have any insight into how sick he is. I think he could do well on medication, but you can't push them."

Nathanial still sleeps on the streets. Because one effect of his illness is lack of insight, he doesn't get the same opportunity to regain control of his decisions.

A film worth watching

"I was sort of at wit's end with all the trials and tribulations," said Smiley, 38. "I wanted to just channel my frustrations."

Susan Smiley’s very personal documentary "Out of the Shadow" chronicles the filmmaker’s mother, Millie, and her family through Millie’s battle with schizophrenia and her subsequent trials within the system.

Millie was just 25 with two small children when she was first plagued by the symptoms of schizophrenia. As mental chaos overwhelmed their mother, Susan and her sister Tina struggled to cope with her.

For years, the family’s ignorance and shame kept Millie’s behavior shrouded in a veil of secrecy. Now, after 20 years of transience and inadequate care, Millie finally has a chance to reclaim her life.

“Out of the Shadow” has been playing to wide acclaim at festivals worldwide and is scheduled to air on PBS stations beginning February 2006. Find out about educational guides and get purchasing information online at www.outoftheshadow.com or via phone at 310 636 0116.

Reader response

An anonymous blog reader submitted the following comment. Because it is fairly typical of some common misconceptions about assisted treatment and our organization, we want to take a moment to respond.

Blogtac reader: Although these tragedies are certainly horrific, I am alarmed that your organization seeks to use them as justification for forced drugging.

TAC: Assisted outpatient treatment is not the same as forced drugging. It is court-ordered treatment that relies on individuals to comply with treatment orders. The majority of people who refuse medication subsequently agree to take it in oral form when informed that they must. “Forced drugging” is a phrase used by those who oppose AOT to scare people into believing that people under orders will be held down and injected. This is not the case. [Read a prior response to a reader on this topic.]

Blogtac reader: Only a very small percentage of the mentally ill are violent and, as yet, there is no reliable way to determine which people will become violent.

TAC: People with severe mental illnesses who are taking medication are no more likely to be violent than the general public. But failure to take medication is one of the top three predictors of violence. Every person with a mental illness is not, of course, violent, but those who are make national headlines, increasing the stigma on the large majority who are not.

Blogtac reader: In addition, many of the violent mentally ill *are* actively seeking help and being turned away before they commit these monstrous acts. This was certainly the case with the gentleman in New York whose crime prompted Kendra's Law.

TAC: In the two years prior to pushing Kendra Webdale to her death in front of a New York City subway train, Andrew Goldstein received 199 days of inpatient and emergency room services, on 15 different occasions, in six different hospitals from1997 to 1999. Four different clinics provided outpatient services in this time period. This is hardly the profile of a patient who was refused services - it was Goldstein who often refused treatment.

Interestingly enough, one of the many positive outcomes of the law enacted after this tragedy is that it has reduced harmful behavior for participants (47 percent fewer physically harmed others).

Blogtac reader: Your remedy (which appears to be force drugging everybody with a psych label) is worse than the problem you are trying to solve. I really hope you reconsider and give a little more thought to civil liberties.

The remedy is to save people’s lives by getting them help before they deteriorate to suicide or homicide or become a victim of violence.

In terms of who AOT affects, it is specifically and carefully designed only for the sickest of the sick, those who are incapable of maintaining their own treatment or making informed decisions concerning it. For instance, Kendra’s Law is used on less than ½ of 1 percent of all the people with bipolar or schizophrenia in the state. [Completely opposite of the prediction of the opposition five years earlier, which may be where you are getting this concept that everybody with a mental illness would be affected ...]

As to civil liberties, don’t take our word for it. Read this essay by the board of directors of the B.C. Civil Liberties Association, “Far from respecting civil liberties, legal obstacles to treating the mentally ill limit or destroy the liberty of the person.” Or some perspectives of consumers (and research on their perspectives) who have actually experienced AOT. Or voices of those who have seen how their lives were saved.

Thanks for the questions.

No death ... but what kind of life?

What passes for good news these days is when people who commit terrible crimes due to symptoms of an untreated mental illness are spared the death penalty.

In Ohio, one prosecutor is mad about it. He swears that Gordon Franklin, 39, will spend the rest of his life behind bars. “We will do all we can to ensure [he] never leaves prison, which is all we can do in this case."

You may remember that Franklin beat his 13-year-old daughter to death with a golf club. You may also remember that he is severely ill with bipolar disorder and was not taking medication.

And California, it looks like the prosecutor will not seek the death penalty for Lashaun Harris, who threw her three children to their death in the bay last week.

There is no good resolution to stories like these – jail is a pretty terrible place for someone with a severe mental illness, and too often you hear that once they are restored to competency, they become suicidal contemplating what they have actually done.

And these cases are far too common. The best solution is to prevent them from happening in the first place. Feeling (understandable) relief that someone won't be put to death for killing their child is a pretty poor second choice.

Who failed Lashaun Harris?

More news on the sad case of Lashaun Harris, the mother in California who threw her three young children to their death from the pier. [Photo is from the Harris family via AP, from happier days.]

- She had a history of schizophrenia and multiple hospitalizations
- She had been hearing voices – that told her to throw her kids in the bay
- She had been off her medication for 4-5 months ("She's been going crazy for a while," her half sister told reporters.)
- On Wednesday, she told her family that “she was going to feed the kids to the sharks.”

People need to start asking why California isn't implementing and using Laura's Law - there is no excuse not to use a law that is saving lives in places like New York,where 74% fewer participants experienced homelessness, 77% fewer experienced psychiatric hospitalization, 55% fewer recipients engaged in suicide attempts or physical harm to self and 47% fewer physically harmed others.

Arguments against implementation ring pretty hollow when you see how many people are being helped in New York (people who, incidentally, are already costing the state quitea bit through emergency rooms and repeated hospitalizations) - and how many people are suffering in California.

Children deserve protection

It was a bad week all around.

In Ohio, a man bludgeoned his 13-year old daughter to death – he was not taking his medication for bipolar disorder.

In California, a woman threw her three young children off a pier to their death – she was hearing voices.

By comparison, these stories make this mother from Vermont look lucky – her son was only arrested. But her plea is too familiar.

"I have been trying desperately to get him some medical help but he has been deemed not dangerous enough to be admitted against his will … In the past, when he got appropriate treatment and followed his care plan, he was not having a lot of problems."

Treatment embraced voluntarily is always preferred - but in some cases, the disease may not make that possible. It is time for us to realize that it is just and humane to intervene long before something devastating happens. Did we learn nothing from the Andrea Yates case?

Averting tragedy is not always politically correct. It is not simple, or easy. It often requires family members to petition the court for intervention, and people who are desperately ill to be treated despite refusing treatment. But it works.

MORE: what is it like to hear voices? * help for overwhelmed family members * state laws

Schizophrenia ≠ Denial

In Ohio, 25-year-old Michael Carreiro says he wasn’t insane when he killed his adopted mother Christine Minnix by stabbing her 15 times.

“(Carreiro) stated that it was a biblical prophecy, that he had been told by God that his mother was evil, and that he was told to kill her,” Middletown detective Timothy Riggs testified in court this week.

“He says that God told him to do it and he was justified,” [his attorney] said following the arraignment. “Like most mentally ill people, he doesn’t believe he is mentally ill.”

MORE: families at risk * violence and lack of treatment * Ohio and treatment

Down the hill to rock bottom...

Ralph Richardson, 50, was severely beaten in the lobby of his East Harlem apartment building on October 13, 2005. Richardson suffered a psychotic break shortly after graduating high school and was later diagnosed with schizophrenia. He lived with his mother until she died in October 2004 and had lived alone since then. His sister said that when she saw her brother the previous month he had lost weight and wasn’t taking care of himself. His sister said, referring to her brother’s medication, "when he goes off it, he goes downhill". Some studies suggest that individuals who are victimized are less likely to have been compliant with their medication.

Help for overwhelmed family members

"We've sacrificed our future and any chance of retiring for him … But what else can you do? I've spent years locked in my bedroom, sleeping on my car keys and with my purse under my pillow. That's the way people live when they have no options." – Contra Costa Times, October 12, 2005

Every day, we get calls and emails from people who are struggling. Some of the suggestions we make are in the following articles …

• Article: Hope for overwhelmed family caregivers: Assisted outpatient treatment significantly reduces caregiver strain
• Article: Families at risk (includes what to do if someone becomes assaultive)
• Article: Getting care for those in crisis, hospitalized, or incarcerated because of a severe mental illness (includes tips on preparing for a crisis and fighting for treatment)
• Checklist: What goes in your CARE kit? (a kit that you can build now and have on hand in case of an emergency)
• Checklist: Important emergency phone numbers to keep on hand (a list to get you started)
• Checklist: What goes in your psychiatric history document? (a critical piece of information for your CARE kit)
• Article: Dealing with a defense attorney

Through the eyes of mental illness ...

If you haven’t experienced it firsthand, it isn’t easy to grasp the burden that severe mental illnesses can place on a person.

Imagine how profoundly different your own life would be if you had to contend with schizoaffective disorder. Even better, imagine it while you read this.

Keep in mind that Clint is apparently not one of those incapable of cooperating with his treatment because of the effects of anosognosia, which can impair or even eliminate the ability of patients to assess their own condition and thus their need for psychiatric care.

The voices suggested I stay

Joseph’s voices told him to stay in his flooded New Orleans home – and he did. For 10 days, he languished with limited food and water. A pararescue jumper and Air Force crew, acting on a tip from a family member, found Joseph in his home, huddled over a small candle flame.

Because he only communicates by writing, their exchange is captured in this note. (Joseph’s initial communication is at the bottom).



The story is compelling not only for the result, but for the compassion shown by all involved to save someone who was, at the time, unable to save himself.

Not fit to fend for himself...

Los Angeles Times columnist Steve Lopez used the recent dumping incident as the platform for this piece.

We appreciate his highlighting that the justification given for hustling a person "not in a fit state to fend for himself" to one of L.A.’s most dangerous neighborhoods was for the person’s protection. The irony is even greater with the knowledge that Byron Harris was subsequently held for a 72-hour emergency psychiatric evaluation, which means that he was sick enough to meet California’s stringent eligibility standard for that intervention.

We are even more interested in Lopez’s comments on those who are homeless and mentally ill in Norway, or - more precisely - that there are none.

"Discharge planning" gone awry

We’ve often stressed the need for discharge planning to ease the transition of people with severe mental illnesses from incarceration to the community. Finding case managers, making appointments with treatment providers, locating housing placements, providing an appropriate supply of medication, and ensuring eligibility for benefits are only some of the steps that can be taken to make sure a person with a serious psychiatric disorder will get treatment and stability rather than a quick return to the jailhouse door.

Byron Harris’ release plan was a bit different - a long drive and a quick dump onto Los Angeles’ skid row. The deputies releasing Harris may not have prevented - indeed, they almost guaranteed - his return to jail, but at least they minimized the chance that it would be to theirs.

"Dumping of homeless suspected downtown"
Los Angeles Times, September 23, 2005