American Psychosis (26 page)

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Whether homeless, living in nursing homes, or living in board-and-care homes, individuals with serious mental illnesses who are living in the community have one thing in common—they are likely to be victimized. A 2008 review of 10 studies suggested that such victimization appears to be becoming more common. For example, among 308 patients living in community residences, 26% percent had experienced a “rape, robbery or mugging” within the previous 6 months. And among 936 seriously mentally ill outpatients, 25% had experienced a “physical assault, rape or sexual assault, [or] robbery” within the previous year. It is doubtful that any group in our society is as vulnerable as seriously mentally ill individuals living in the community. They are, in the words of one reporter, “rabbits forced to live in company with dogs.”
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EFFECTS ON COMMUNITY RESIDENTS

Individuals with severe mental illnesses are not the only victims of the breakdown of the mental illness treatment system. Many community residents are victims as well insofar as they no longer feel comfortable going downtown to shop or using community parks and playgrounds. Homeless individuals, especially those who are mentally ill, have expropriated public spaces in many American communities.

San Francisco provides an especially sad example. As described in 2008 by one resident:

One is hard pressed to walk around just about any neighborhood without having to run a gantlet of panhandlers, step over passed-out drunks or drug addicts, maneuver around the mentally ill or try to avoid the stench of urine and the human feces littering the sidewalk. . . . I often feel sorry for the confused tourists who take a wrong turn off Union Square only to find themselves in the sudden squalor of the Tenderloin or the Hell-on-earth intersection of Sixth and Market streets. . . . In 2007, a homeless man snatched a woman’s baby away from her and attempted to throw it over the railing above the Powell Street MUNI/BART station, but was stopped by several onlookers.

San Francisco has no monopoly on such frightening behavior. In Los Angeles in 2011, a mother pushing her infant son down the street watched in horror as another woman grabbed the child by his leg and swung “the child over her head . . . slamming him into a metal rail.” The severely mentally ill woman told police that “she tried to break off the baby’s arm so she could eat it.”
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Less dramatic variations of such scenes are being played out in every American city. Among those being victimized are shopkeepers and store owners, whose businesses suffer because customers find shopping downtown too unpleasant. For
example, in Fort Lauderdale in 2008, downtown business owners complained about homeless individuals on the streets “leaving the rancid smell of urine, stealing food off plates at outdoor cafes, chasing away business and offending tourists.” Such problems are completely predictable. As two observers wrote as early as 1973: “To discharge helpless, sick people into the streets is inhumane and contributes to the decline of the quality of life in the urban environment.”
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The situation with public parks and playgrounds is even worse. Nobody has yet made a count of the number of such places that have been effectively lost to public use because they have been taken over by mentally ill homeless individuals. Walking your dog or teaching your child to ride a bike amidst men and women who are merely drunk or drugged is unpleasant, but doing so amidst psychotic men and women who are angrily shouting at unseen voices is frightening. In addition, many city parks are now devoid of benches or other places to sit because they were removed to discourage people from sleeping there. Cities such as Santa Monica, Las Vegas, Orlando, and Fort Myers have tried to restrict the use of city parks by homeless persons, arguing that such people should use the existing soup kitchens and public shelters. Such ordinances have been challenged by civil liberties advocates. In Las Vegas, for example, it was claimed that city parks are especially important for mentally ill people because “the chronically mentally ill who make up a sizeable part of the homeless population typically resist treatment and services” and often will not use public shelters.
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Another community facility that has been profoundly affected by the deinstitutionalization of mentally ill individuals and our failure to provide treatment for them are the public libraries. Many libraries have become day centers for mentally ill people who are homeless or living in board-and-care homes. A 2009 survey of 124 public libraries, randomly selected from all parts of the United States, asked about “patrons who appear to have serious psychiatric disorders.” The librarians reported that such individuals had “disturbed or otherwise affected the use of the library” in 92% of the libraries and “assaulted library staff members” in 28%. Eighty-five percent of the libraries had had to call the police because of the behavior of such patrons. This included benign activities such as a “patron rearranging reference books by size and refuses to stop” to less benign activities such as a man running “through the circulation area, near the children’s department, repeatedly without clothing.”
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Libraries have attempted to cope with these problems in a variety of ways. Some, such as Maryland’s Hagerstown public library, have hired “security personnel [who] now blend in with patrons as they keep an eye on things.” A San Francisco public library, in which the majority of patrons were said to be homeless people, hired a full-time social worker. Other libraries are training staff how
to respond to disturbed mentally ill individuals using a 12-hour course, “Mental Health First Aid.” Despite such efforts, many people are now reluctant to use public libraries. As noted by librarians, “many, many library customers don’t come downtown to our Central Library because they’re afraid of these customers”; “a number of patrons have told us they will not be back because of unpleasant encounters they feel are unsafe”; “patrons are often frightened by strange behavior. . . . [They] hold onto their children more tightly and leave more quickly than they might have planned.” Although public libraries have been an important part of American culture for two centuries, they are becoming yet another victim of the failed mental illness treatment system. As one librarian summarized it, “This problem [mentally ill persons in libraries],
not the invention of the Internet
, could prove to be the final demise of the public library as we know it.”
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Another public space that has been markedly affected by the increasing numbers of untreated mentally ill individuals in the community are hospital emergency rooms. This problem surfaced on public radar in 2008 when Esmin Green sought psychiatric help in the emergency room of New York’s Kings County Hospital Center. After having waited for 24 hours, a physician wrote an order on her chart to get blood tests and an X-ray and to use “sedation/restraints if needed.” They weren’t needed, because by the time the order was written, Ms. Green had been dead for more than an hour on the floor of the waiting room. Videotapes, which were widely played on television news shows, showed her lying there as two security guards and a hospital psychiatrist observed her but did nothing. In fact, in the period after she had died, notes written on her emergency room chart claimed that she was “sitting quietly,” was “up and about,” and “went to the bathroom.” An autopsy showed that Ms. Green had died from blood clots caused by sitting too long.
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Perhaps the most shocking part of this episode is the fact that Ms. Green, if she had lived, would have had to wait
only
24 hours to be seen. A national survey reported that almost 10% of all emergency room visits are now for psychiatric problems, not including substance abuse. Because there are very few remaining public psychiatric beds in the United States, emergency rooms become backed up with psychiatric patients waiting for beds.

2007: “Patients with acute mental illnesses are increasingly forced to wait up to three days in Georgia hospital emergency rooms before being admitted to state-run mental hospitals. . . . ERs in Georgia are already overwhelmed with the rising number of uninsured. . . . ‘The mental health problem only exacerbates this [crowding] problem,’ ” said a hospital association official.

2008: A Washington State task force reported that many severely mentally ill people, including those with histories of violent behavior, “are being detained in hospital emergency rooms that aren’t staffed to care for them.”

2009: In Texas it was reported that nine individuals, seven of whom had “mental health issues,” accounted for 2,678 visits to Austin emergency rooms between 2003 and 2008. The average cost of each visit was $1,000 and was paid by Medicaid or Medicare.

2010: In North Carolina it was reported that “on average, people in the midst of a mental health crisis can expect to languish in a medical hospital’s emergency department for 2.8 days before gaining admission to a state psychiatric hospital.” In the western third of the state, the average wait was 4 days. In a three-month period, Wake County had “13 people waiting a week or more.”

2011: In Massachusetts “so many people seeking psychiatric help flooded Quincy Medical Center’s emergency room . . . [that] 20 beds had to be set up in a nearby conference room to handle the surge.” The chief of emergency medicine at the medical center said “he had seen the situation deteriorate dramatically” since 2002.

2011: In South Carolina “mentally ill patients are flooding into emergency departments as a direct result of deep cuts for treating these troubled individuals.” One woman had been in an emergency room for 8 days awaiting a psychiatric bed, another woman 12 days. According to a Hospital Association report: “South Carolina’s hospital emergency rooms have become the safety net for the mentally ill.” The director of the emergency room in Pickens said: “They say it is going to get worse but I don’t know how. It is really horrendous.”

2012: In California, Fresno County officials were forced to reopen the county’s psychiatric crisis center. Since it closed in 2009, “as many as 600 psychiatric patients visit the hospital’s emergency room each month, more than double the number that went there before the crisis center closed.”
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VIOLENT BEHAVIORS AND HOMICIDES

The most publicly visible consequences of the failed mental illness treatment system are violent behaviors, including homicides. As previously noted, such acts became prominent in the early 1970s in California as deinstitutionalization accelerated, and they appear to have continued to increase over the subsequent 40 years.

It important to note that most acts of violence are not committed by mentally ill individuals and that most mentally ill individuals are not violent. Being a young male or a substance abuser is a much higher risk factor for predicting violent behavior than is being mentally ill. It is also true that individuals with serious mental illnesses are
more likely to themselves be victimized than they are to victimize others. All this is true, but it is
also
true that a small number of individuals with serious mental illnesses, especially those who are not being treated, are responsible for a disproportionate amount of community violence, including homicides.

Between 2007 and 2009, four review studies were published on the relationship between untreated serious mental illness and violence.

• A review of 22 studies published between 1990 and 2004 “concluded that major mental disorders, per se, especially schizophrenia, even without alcohol or drug abuse, are indeed associated with higher risks for interpersonal violence.” Major mental disorders were said to account for between 5% and 15% of community violence.

• After reviewing the psychiatric literature from 1970 to 2007, the author of another study concluded that “sound epidemiologic research has left no doubt about a significant relation between psychosis and violence, although one accounting for little of society’s violence.”

• An analysis of 204 studies of psychosis as a risk factor for violence reported that “compared with individuals with no mental disorders, people with psychosis seem to be at a substantially elevated risk for violence.” Psychosis “was significantly associated with a 49%–68% increase in the odds of violence.”

• A review of studies from 11 countries involving more than 18,000 patients concluded that, compared to the general population, men with schizophrenia had a two to five times greater risk for committing violent acts, and women with schizophrenia had a four times greater risk.

It should be emphasized that almost all the increased risk of violent behavior by individuals with serious mental illnesses applies only to those who are not being adequately treated with medications. For those who are being treated and take their medications, there is no evidence for any increased risk.
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Although most public attention regarding serious mental illness and violent behavior is focused on homicides, there are other examples of this problem. During late 2011 and early 2012, for example, Ali Shahsavari, with untreated schizophrenia, caused an emergency landing of a Southwest Airlines flight in Texas when “he intimidated crew members by screaming profanity” during the flight; Oscar Ortega, with untreated schizophrenia and a belief that he was Jesus Christ, shot at the White House in Washington; and Gregory Seifert, with a severe mental illness, used a chainsaw to cut down utility poles near Buffalo, causing a loss of power to more than 6,000 homes.
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