Thursday, May 18, 2017

Crazy on the Streets: What Do You Want Us to Do?


Recently I passed a crazy woman as I walked past the Starbucks in my neighborhood.

She was old, or at least she looked old, and she most likely was homeless.  She wore a black knit hat and a dirty sweater, and she had a green blanket wrapped around her knees.  

She was yelling in a furious tone, "fuck them" and "fuckin that," apparently to a person who existed only in her head.  Everybody in the area was pretending to ignore her. 

After I had crossed the street, I called the non-emergency desk at the police department and described the woman and her bizarre behavior.  

"Is she a danger to herself or to others?" asked the desk sergeant.

"I don't think so," I said, "but she's having a psychotic episode."

"What do you want us do?" asked the sergeant.



The Legal Situation

In 1975, the U.S. Supreme Court ruled unanimously in Donaldson v. O'Connor that Americans cannot be detained for psychiatric reasons without due process and unless they present a danger to themselves or to others.

The complainant's case reads like something out of Kafka.  In 1956, he was sent to a Florida mental institution after a single hearing, over his objections and without legal representation. Yes, he had delusions, but he also had 48 years of life experience and had never been in trouble.

It took him 15 years to get out.  His first 18 appeals were denied based on his initial diagnosis -- paranoid schizophrenia --  but he received no treatment and effectively was imprisoned along with 1,000 other men, many of them criminals, whose needs were addressed by a single doctor (a gynecologist!) and one nurse.  

During the man's incarceration, a halfway house offered to take him in.  So did a college friend who was willing to take responsibility for him.  Those offers, like his many appeals, were denied, always based on the initial diagnosis. 

After his release in 1971, the man took and held a job, lived on his own without problems and wrote a book describing his experience.

The ACLU took his case to the Supreme Court and won.  This was a good thing.  The 20th century saw many totalitarian governments imprison dissidents as "mentally ill."  Our country is better than that.

Now psychotic people have civil rights, but there is a tension.  Being crazy on the streets can lead to any number of bad results, including victimization by non-benign others. The few who are dangerous or just scary looking often end up in jails, which are particularly stressful for people with psychosis.  If jail doesn't help people with cancer, is it reasonable to expect that it would be therapeutic for people with brain diseases?


-----

While I was making coffee early this morning, I heard a man yelling as he walked past our apartment.  He was chanting "Motherfuckhead!" repeatedly.  The noise grew louder as he passed our door and ebbed as he continued down the street.  
        This happened twice before in the last six months; the good thing this time, for me, was that I was already awake. 
        Last month I saw another man walking and screaming as I waited for an airport taxi;  his clothes were filthy and he knocked over garbage cans as he raged, loudly, across the street.
        I am not a diagnostician, and so I am not sure how to tell the difference between organic psychosis and a PCP- or meth-induced psychosis. My guess is these young street-walking screamers fall into the latter category.  The others, not so much.  

-----

I used to live in a neighborhood with many homeless people, some of them crazy.  One was a beautiful young woman whom I saw walking on the streets.  She talked to herself, never made eye contact and pretty clearly was disconnected from reality.  
        After a few months, she was obviously pregnant.  I don't believe she had the mental clarity to consent to sex.  I have no idea what happened to her and her baby, but I think about them still.
-----

The year after my mother died, I went to a noonday church service on her birthday.  I couldn't send her a present, and I figured she would have liked for me to do this instead.
        Shortly after the service began, an older woman, deranged, walked up and down the aisle yelling in foul words about things in her head.  Then she sat down in the back of the church for a while.  After a while, she got back up again and stormed around, yelling, for the remainder of the service.
        Everybody in the church, including the priest and including me, pretended she was not there.  By law, she had the right to be crazy.  Given religious custom, she was welcome in the church.  
        But she needed help, and we did nothing to help her.

-----

One day, I walked across a park on my way to a business appointment.  I passed a handsome young man who was sitting on a bench and opening a can of food with a can opener. We looked at each other briefly, and I nodded at him.
        "Lady, did you just make a threat to me?" he yelled.
       "No!" I said, and scooted away.




Conclusion

These are just a few of my stories, and I do not pretend that they are the true face of the homeless mentally ill.  There must be many other irrational people hiding in the shadows, fearful and silent, detached from reality and paranoid, perhaps sometimes with cause. 

We've seen a lot since that 1975 court ruling, including an explosion in the number of crazy people living on some pretty mean streets. This does not reflect well on us.  I sure wouldn't want a relative or friend of mine in such a vulnerable situation.

But then there's a police sergeant's question:  What do you want us to do?

I don't like the idea of a paternalistic government. I wouldn't want to be locked up "for my own good," as defined by some police officer or doctor who didn't know me.  On the other hand, I have most of my marbles, at least on my better days, and my life situation is one of relative safety.  I appreciate this.

Maybe it's time for a rethink.  If a person behaves irrationally and is in danger of being hurt by some of the bad people on the streets -- the tweakers, the thieves, the rapists, the childhood bullies grown into adult thugs --  must we assume that his impaired decision-making does not constitute a danger to himself?  

Can we not offer a brief, quiet stay in a medical facility (not a jail holding pen) where the person could be evaluated and encouraged to work toward a safer, less chaotic life?  In that space of safety, could the person's family and friends not be invited to join the effort and offer their support? 

Our scientific understanding of brain function is still primitive, but it's come a long way since 1975.  There are more medications and certainly more therapists and doctors who have worked with these people, with greater success.

The biggest failure of the de-institutionalization of the mentally ill in the last century was the failure to replace big institutions with smaller ones that offered consistency, professional backup and much more personal freedom to psychotic people.  As we reduce our prison populations, can we not build more small group homes? We need more of them.  

Put it another way:  If crazy people have rights, don't the rest of us have responsibilities?


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