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, founded on individual rights, aims to be 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 and prisons, 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?  And, if we are responsible, what should we do?

No One Cares about Crazy People

The cover illustration of this book -- the title words at the bottom of a dark empty box -- struck me as odd until I started reading.

The story documents, in personal and societal terms, the suffering and costs of psychosis in America today.  As I read, I realized the illustration is a metaphor for the profound isolation of people with serious mental diseases.

Author Ron Powers ("Flags of Our Fathers," "Mark Twain: A Life") has switched from his third-person perch to write a book that is personal and historical and somewhat clinical.  

He and his wife, a scientist, raised two bright sons, each of whom developed schizophrenia in late adolescence.  Early on we learn that one of the sons hanged himself and died alone in the family basement one night, only to be discovered the next morning by his father.  

This is powerful and painful stuff, but Powers uses it to good effect, talking about the boys' joyful early years and then the parents' discoveries that their children's thinking had strayed from reality.

Interspersed with the family tale are historical recounts of how people who are different have been treated through history, particularly in the U.S. since about 1960.

Psychotherapy Today

I always had heard that insane asylums began to be shut down in latter part of the 20th century.  Powers explains how and why it happened.

First, he says, the FDA approved Thorazine, the first drug for treatment of psychotic disorders, for use in the U.S. in 1954.

This was a perhaps naive period.  After the introduction of antibiotics and the polio vaccine, Americans may have believed that science soon would yield treatments, or even cures, for every imaginable disease or disorder. 

Unfortunately, Thorazine wasn't a magic bullet.  Its effect, making more dopamine available in the body, did not address the causes of mental disease.  It also had unpleasant side effects:  dizziness, drowsiness, anxiety, sleep problems, weight gain, swelling of hands and feet, blurred vision and, worst, permanent involuntary tics and muscle twitches.

No matter. Within 10 years, 10 million Americans were taking Thorazine.  Then came lithium and many other anti-psychotic medications.   Some are helpful, but each case of mental illness is unique, activated by different brain reactions as well as individual life events and stresses.

Then, in 1961, psychiatrist Thomas Szasz published a groundbreaking book “The Myth of Mental Illness” that questioned the legitimacy of his field and provided intellectual cover for generations of anti-psychiatry activists, including L. Ron Hubbard, the sci-fi writer who founded the Scientology religion or movement or whatever it is.

(My note:  In 1962, author Ken Kesey published "One Flew over the Cuckoo's Nest," a novel set in an insane asylum where residents were treated with lobotomies and stupor-inducing drugs designed to enforce passive conformity.  The story became a popular movie in which a gleeful rebel played by Jack Nicholson battled with a mean nurse.) 

All this noise about magic medications and individual freedom caused legislators and insurance companies to de-institutionalize masses of psychotic people. 

Over time and as the national population increased -- by more than 100 million between 1960 and 2000 -- the number of beds for psychiatric inpatients declined by 95 percent.

Since then, we have not created the promised small group homes or communities that would have offered refuge and, ideally, steady support for psychiatric patients to live more independent lives.   

Jails and prisons, stressful places for all but particularly for the emotionally fragile, now have replaced insane asylums as the institutions that house our largest populations of psychotic people.  The asylums may have been bad, but the prisons are more expensive and much, much worse.

Anosognosia 

As Powers winds up his book, he introduces a term that I had not encountered before: anosognosia. 

Anosognosia is the diagnosis when a sick person is unaware that he is sick -- not in denial but detached utterly from reality. 

Powers tells of receiving a phone call early one morning from a son who announced that he had received a great honor in the middle of the night and that he was on his way to pick up his prize.  The parents, heroically committed always (and who wouldn't be?), scrambled to intervene.  This was not the first time one of their children needed such help.   

It is not unusual for psychotic people, once stabilized on medications, to become convinced their medicines are no long necessary and to stop taking the medicines; the resulting deterioration in their situations is challenging even for those with fully involved families and well-organized support systems.  

Powers applies the word in a broader sense.  As a country, he suggests, we also suffer anosognosia.  We willfully ignore the problems suffered by people whose brain chemistry is causing them great pain.  His book is a scream for his children and for others like them, a scream to the rest of us to take these matters seriously.

Next: