Housing the homeless...who aren't psychotic

In an op-ed in the LA Times, two experts on homelessness and skid row wrote:

The central antidote to homelessness is not a police sweep or a shelter bed. It's housing.

Once housed and given appropriate support and services, formerly homeless people with mental and addiction disabilities -- those for whom we used to think a bowl of soup and a blanket was the best we could do -- have a good chance of staying off the streets.

Certainly, they are right. For many of the people on skid row housing and services are enough. But what about people with mental illnesses so severe they have anosognosia, or a lack of insight into their illness? What about those who are so sick they will never chose mental health treatment? (Remember Nathanial?)

Without assisted outpatient treatment to accompany housing and services, the sickest of the sick are still being ignored.

Star of stage, screen, and skid row

Sounds like Hollywood is poised to make another heartwarming movie about someone with mental illness who overcomes the odds. Jamie Foxx is set to play the part of Nathaniel Anthony Ayers, who "like 1% of the population has schizophrenia, sleeps on the sidewalk on skid row. His misfortune is to have the one disease for which there's no poster child, let alone a national telethon."

That quote comes from Steve Lopez, a columnist for the LA Times who has been chronicling Nathanial's life. He has pulled his observations together into a book, which will be the basis for the movie starring Foxx.

Nathanial's family, according to Lopez, couldn't get him to stay in treatment.

As do so many schizophrenics, [his sister] Ayers-Moore says, her brother would improve with medication but then refuse to take it and slip back into his tortured
world.

On October 23, 2005, Lopez noted:

Nathaniel is too sick to know he's sick, so he resists treatment that might give him a shot at a better life, and I now understand the frustration of hundreds of families that have told me in agonizing detail of similar dilemmas.

Lopez wasn't content to write about Nathanial - he wanted to help him. And to get others to help him. And he did. In fact, the time and energy put in by so many at Lopez' behest to help Nathanial is beyond touching.

Yet the effort seemed to shift from rescue to rehabilitation - if we can only get Nathanial to trust us and choose housing, the message became, we can save him. After a full year of engaging him, the experts assessed that he was "close" to moving into the apartment they had secured, and furnished, for him.

Another year on the streets.

What eventually happened to Nathanial will likely make a moving and interesting film. But it should also make us angry.

It took 30 years of homelessness, a background as a world-class musician, and the rapt attention of a renown LA Times columnist to get Nathanial moving along the path - not to treatment, but to possibly, someday, getting treatment. Even then, the goal was to help Nathaniel finally choose housing as a first step to get back some of what he lost in the last 30 years.

At one point in the real-life drama, Lopez asked the prescient question, "With treatment, who knows what he could be capable of?"

Indeed. It is certain Hollywood will slap a happy ending on this story. Expect to see Nathanial at the premiere and for everyone to feel good about lifting this man back up.

Will that make up for society completely neglecting to help him for three decades?

Or make a difference to the thousands like him who still sit on skid row?

Guest Blog: Pennsylvania’s Advocacy Effort to Change Treatment Laws

GUEST BLOG:
Written by Jeanette Castello, Co-Chair of the Pennsylvania Treatment Law Steering Committee

According to Pennsylvania’s treatment laws the crisis worker who told Marjorie Miller that she was not able to take Kenneth Miller to be admitted to a hospital was just following the law.

Members of an advocacy effort to change our treatments laws are currently working to see Pennsylvania Senate Bill 226 passed so individuals with severe mental illness and a history of hospitalizations, homelessness, and/or time spent in jail or prison will be able to receive the timely, compassionate treatment they need. SB 226 is modeled after the proven successful Kendra’s Law. This law helps the small minority of people - who are often non-compliant with prescribed medications - to remain in treatment and possibly avoid the tragedies of violence and victimization that too often occur.

Although violent incidents are the ones the media often report on, my personal involvement with this advocacy effort is due to the unbearably heartbreaking time when my daughter suffered from lack of insight into her illness, also know as anosognosia. During this period of time, my daughter was hospitalized 15 times, each time meant a wait for her to reach the “clear and present danger to self or others” required by law. My concern during those sleepless, stress-filled days and nights was the worry that she would be hurt while wandering, sometimes in the middle of the night, following the voices that told her to leave the house.

Opponents of changing our treatment laws say we’re trying to infringe on their rights. Which makes more sense to you? 1) allowing our loved ones to put themselves or others in dangerous situations such as happened to the Miller family or 2) requiring compassionate and timely outpatient treatment for six months (the initial period of time stated in Kendra’s Law and SB 226). As a society, we need to decide what makes the most sense.

- Jeanette M. Castello
Co-Chair, PA Treatment Law Steering Committee
send comments to Jeanette through info@treatmentadvocacycenter.org

The opinions expressed by guest bloggers are their own and not necessarily that of the Treatment Advocacy Center.

Want to be a guest blogger? Tell us why at info@treatmentadvocacycenter.org.

Anosognosia: An Inconvenient Truth?

Mental health advocates who argue that court-ordered treatment is a violation of civil liberties conveniently disregard some scientific facts: severe mental illnesses are diseases of the brain, the very organ that allows us to reason and deliberate; some people with severe mental illnesses are affected to a degree that they are unable to make reasoned treatment decisions for themselves; anosognosia also occurs in some some individuals with strokes, brain tumors, Alzheimer’s disease, and Huntington’s diseases; that this “lack of insight” is a major cause of refusal to take medication; and, that medication can benefit many patients with schizophrenia and bipolar disorder.

Take the Bazelon Center for example. In their blanket opposition to assisted outpatient treatment, they summarily dismiss the science of anosognosia by referring to it as a, “…supposed "lack of insight" on the part of the individual, which is often no more than disagreement with the treating professional…”

There are now more than 100 studies documenting “lack of insight” in individuals with severe mental illnesses. How much longer will treatment opponents ignore the research and continue to make the same uninformed arguments?

New study on the role of insight in violence & criminalization

An upcoming study of factors contributing to violence and criminality of patients with schizophrenia illustrates the importance of addressing lack of insight and treatment nonadherence.

Researchers reviewed German crime registries for records of criminal offences committed by 1662 patients with schizophrenia treated between 1990 and 1995 at the Psychiatric Hospital of the University of Munich. Of the 1662 individuals, one hundred and sixty nine (10.2%) had been convicted in the 7–12 years after discharge. The rate of violent crimes was especially high: 62 (3.7%) patients were convicted for physical injury offences. Significantly higher rates of criminal conviction and recidivism were found for patients with lack of insight at discharge.

When the brain fools itself

The Treatment Advocacy Center’s advocacy is based in large part on the increasing evidence of the role that anosognosia, or lack of insight, plays in causing patients with schizophrenia and bipolar disorder to believe they are not ill and therefore refuse needed treatment.

It is sometimes easier to conceptualize the impact of the neurological deficit, anosognosia, as it occurs in other brain disorders. In a fascinating article about the brain, Shelby Martin describes a famous case of anosognosia:

In his book “Descartes’ Error,” neurologist Antonio Damasio describes the 1975 case of Supreme Court Justice William Douglas. A debilitating stroke left him confined to a wheelchair, paralyzed on his left side. Against medical advice, Justice Douglas checked himself out of the hospital, dismissing reports of his paralysis as “a myth,” and publicly invited reporters to go hiking with him.

Douglas, like other patients with anosognosia, was completely unaware of his injury. He went so far as to claim he was kicking 40-yard field goals with his paralyzed leg. Clearly delusional, Douglas was forced to retire from the Supreme Court.