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Sunday, June 10, 2007

Mental Illness and the Price of "Free Will"

A few months ago after I drove my daughter to school, I drove through the local drive-through dairy to purchase the newspaper like I always do. Across the street, I saw a homeless man, obviously distressed from his loud rantings into the air, lighting matches and throwing them to the ground. Having worked with the homeless in the past, and knowing the law, I did not know exactly what the right course to take was, but I knew I had to do something because this man was obviously in distress.

Twenty years ago when I worked with the homeless on a regular basis, AFTER the mental hospitals were emptied of their patients a new law was enacted in California, the Lanterman Act, which created community clinics to take care of the mentally ill who had been released. At that time also there were mobile clinics which went out to specific areas to monitor the medication of these patients who needed them to live properly.

Since that time, the funding for the mobile clinics in most areas has dried up and many of the local clinics have also closed, and the mobile clinic where I reside, no longer exists. The mobile clinics AT LEAST kept a closer track on these patients and were more accessible. As the below article states, the ONLY way a mentally ill person can be forced to take medication and put in a safe place is if that person is deemed a threat to himself or others. But in assessing the "patient" many different entities, some of whom have NO training in mental health, are the ones to make this decision.

That day I saw this homeless man in distress, I KNEW I had to do something. But who to call was the issue. So I reluctantly called the local police department and explained to the desk sargeant that there was a man in dire need of help. Within a few minutes the police arrived. They got out of their patrol car and approached the man sitting on the ground, filthy, shouting incoherently, lighting matches. They forced the man to his feet and handcuffed him. At that point I got out of the car and asked them very firmly to be more gentle. They ordered me back to my car in no uncertain terms. I explained to them that I had been the one who had called but again they told me, "GET BACK IN YOUR CAR MA'AM".

I persisted and asked them where they were taking the man. They replied, "We are taking him to the station and booking him on attempted arson".

"Attempted arson? He NEEDS to be sent to a hospital for treatment!" I responded.

"Lady, that's not our business" they replied, "We are law enforcement and he is breaking the law"

I begged them to call an ambulance and they refused. They even threatened me with interfering in an arrest. They forced the homeless man who was struggling against them into the police car and I fully assume took him to jail to be booked. More than likely after that, he was released back on to the streets.

What did this incident teach me? (along with other knowledge such as written below)
It taught me that the mentally ill are NOT cared for in our society. They are thrown away onto the streets and unless you can coax them in, there is no recourse. It also taught me that people who are NOT trained and who have apparently NO compassion and are themselves restricted by the law, are the ones dealing first hand with the mentally ill in the public. Many of these mentally ill people end up in jails when they commit crimes, many end up in hospitals for specific health problems and then all end up back in the netherworld of the forgotten and uncared for mentally ill.

This is a crime against humanity, this is a sin against our creator.

Mental illness and the price of 'free will'

Are laws protecting the right to refuse psychiatric treatment doing more harm than good?

By Susan Partovi, SUSAN PARTOVI is a staff physician at the Venice Family Clinic and an assistant professor at UCLA's David Geffen School of Medicine. She is also the medical director for Homeless Health Care Los Angel

June 10, 2007

THE PHONE RANG at 3 a.m. "Dr. Partovi," the person on the line said, "I'm calling to let you know that William expired this morning."

I'd first met William about six months earlier in May 2006 at the Venice Family Clinic after his release from a hospital where he was treated for congestive heart failure. I still remember his loud, childlike voice: "No, no … I'm not going to the hospital!" he shrieked when I told him that I wanted to refer him to Harbor-UCLA's cardiology clinic.

William — I'm calling him that because medical privacy rules don't allow me to use his real name — was 61. Six feet tall with gray hair, he dressed in T-shirts and pants that were a little too big. He lived alone in an apartment in Brentwood and had a sister in Canada and a niece in New Jersey.

Three years earlier, he'd had a heart attack and a stroke, and he now suffered from dementia, likely as a result of the stroke. It was quickly obvious to me that William could not take care of himself anymore. He spoke like a whining toddler. He was very stubborn, and his judgment was extremely limited. "My memory's not good," he'd huff if he couldn't answer a question.

But one's inability to care for oneself is not a criterion to receive involuntary treatment for the mentally impaired. And for many mentally impaired people without family nearby to rely on for housing, food and help in managing their medical care, the result can be disastrous.

A recent study of adults with serious mental illness who were treated in eight states' public hospitals and clinics found that they died, on average, at age 51 — 25 years younger than the average American. The study's lead author, Dr. Joseph Parks, director of psychiatric services for the Missouri Department of Mental Health, said that about three out of five died of preventable diseases.

William's heart failure was very treatable, but only if he would take his medications appropriately.

I continued to see him every two weeks or so at the clinic. At first he was brought by a female friend, and then after she disappeared, by a new friend, Mike. Mike kindly made sure that William had food, checked that his bills were in order and put his medication into daily pill boxes. When, after a few months, Mike confessed that he'd met William only recently when buying one of his boats and couldn't continue to be this involved, I understood.

I asked one of the clinic's volunteer psychiatrists to see William, and she chatted with him for a bit during his regular clinic appointment with me.

Though he seemed to like her, he would never go to her office at the Edelman Westside Mental Health Center, a county clinic, and neither of us could make him go. I also called the county office that handles elder services — which investigates impaired adults to learn whether they suffer from abuse, isolation or neglect — but he kicked the social workers out. "He's got a personality problem," one of the social workers said to me afterward. "We can't help him."

William's health deteriorated, and he landed in the emergency room with abdominal pain — most likely angina related to his heart failure. I asked for a psychiatric consultation; if William were deemed incapable of making his own decisions, we could try to get him placed in a long-term care facility.

But the hospital psychiatrist claimed that William knew his name and where he lived — and that he was very insistent on not being placed.

"But he can't take care of himself, he doesn't have food, he can't pay his bills, he won't take his medications," I replied.

"It's his free will to not take his medications." Thus, he was deemed "fully competent."

A woman who'd been assigned by the hospital to sit with William in his room took it upon herself to become his home health caretaker after he was released. She cleaned his apartment — which she described as unlivably filthy — washed his clothes, stocked the fridge. But it lasted only three days. He became so verbally abusive that she left.

Mike called a few days after that. He'd found William naked on the couch, claiming that he couldn't find anything to wear.

I thought that he should go to Harbor-UCLA Medical Center, where I could try to get another psychiatric consultation. Mike agreed to take him, but William refused to go.

He'd still come to his now-weekly appointments at the clinic, but he stopped taking the drugs that controlled his blood pressure, cholesterol, fluid levels and agitation. He would only say, "I promise, Dr. Partovi, I'm going to do better," like a 3-year-old promising not to hit his sister.

The next phone call came from his landlord. "William looks very sick," she said, "but he won't go to the hospital."

When I called to check on William, he sounded breathless. Yet, when I mentioned the hospital, he slammed down the phone.

I called the county's psychiatric emergency team but was told that its members couldn't force themselves into someone's house, and I knew William wouldn't let them in voluntarily. The unit recommended asking the police to do a courtesy check. But the police said they weren't allowed to force entry either.

William had gained more than 50 pounds in fluid. I begged him to go to the hospital, but he vehemently refused.

"Do you want to die?" I asked, exasperated.

"No, no, I don't want to die," he'd squeal in his childish voice. But he couldn't understand that he was killing himself.

The next Monday, he came to the clinic, complaining of chest pain. The attending physician called the paramedics to take him to the hospital. He again refused to go.

"Do you know your name?" one paramedic asked. "Do you know where you are?" These are the standard questions non-psychiatrists ask to assess one's mental state.

"The Venice Family Clinic," William said, sing-songy.

"He's competent," the paramedic said. "We can't take him if he refuses."

A few days later, I got a call from William's new roommate, John. He was in a panic: "Dr. Partovi, William looks horrible. He can't get off the couch, and he's hallucinating. He's barely breathing!"

"Call 911," I told him. I could hear his hesitancy in the silence. "He's going to die on your couch if you don't."

John called 911, and paramedics took William to the emergency room.

"We'll get him tuned up," the ER physician assured me. I could hear William's boyish cries in the background, "No, no, no!"

That night I got my last call about William. The one that came at 3 a.m.

Since the deinstitutionalization of the 1980s, when state laws protecting the right to refuse psychiatric treatment were strengthened, it has been extremely difficult to involuntarily hospitalize the mentally ill or mentally impaired. Though psychiatrists are the only ones who make legal determinations, other physicians, the police and the paramedics all know the criteria: "If the patient is at risk of harming him/herself or others … "

But what is harm? Wasn't William harming himself? And aren't we allowing him to harm himself under the guise of "free will?"

There's a homeless man in Santa Monica who sits on the same stoop all day, every day. He has matted hair down to his hips, long nails and a honeydew melon-sized hernia easily visible under his filthy clothes. He's quite benign, but he refuses anything from me or the outreach workers I go out with. Isn't he harming himself? Isn't it harmful to live in the streets, not bathe, not seek a doctor's attention for a chronic condition?

In the wake of the massacre at Virginia Tech, we've been repeatedly told that we all need to be able to spot the warning signs of mental illness. But it's not rocket science. Seung-hui Cho was severely mentally ill — and there were several attempts to "help" him by his teachers at Virginia Tech, whose efforts were thwarted.

The law allows people their free will to refuse treatment. As someone on the front lines of treating the mentally ill, I would like to see the law take better care of people like William, the homeless man with the hernia and Cho — and, by extension, the 32 people he killed.

Perhaps the issue confronting us is not about free will at all. Perhaps it's about our own disinclination as citizens and taxpayers to fund more treatment facilities, counselors and hospitals for the mentally ill. And perhaps "free will" is the propaganda we've decided to believe instead.


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