On Mental Illness and Civil Liberties

When medical treatment is the difference between life and death, refusal of care is usually not an option. But should this same rule apply to mental illness? Particularly when medical care could save hundreds of thousands of people from living on the streets?

I know, quite a heavy question for a simple Tuesday afternoon. But a provocative piece in today's LA Times got me thinking about the unmistakable connections between homelessness, healthcare, and mental illness. Although it's difficult to know precisely what percentage of the homeless population is afflicted with mental illness, estimates range between 16 and 33 percent, it's clear that a causal connection exists.

LA Times columnist Robert David Jaffee attacked this question head-on today and in a very personal manner. He provides a vivid foray into his delusional relapse in 1999 when he stopped taking his psychotic medications. Here's a small excerpt:

On the night of Jan. 22, 1999, I barely slept. My mind raced with thoughts that the CIA or FBI was trying to monitor my speech. I became convinced that the cat had been programmed by the government.

When my then-girlfriend, Barbara, finally woke up the next morning, I told her what I believed to be the terrible truth: I was going to be blamed for a synchronized series of murders across the country, and I needed to document my whereabouts to prove I was innocent.My petite girlfriend tried to hold on to my wrists to prevent me from leaving. She was so strong that I figured she too had been trained by the CIA. Careful not to hurt her, I broke away and left her Glendale condominium, starting on a harrowing, six-hour trek across L.A. County, convinced that I was going to be assassinated.

Scary, huh? After checking himself into UCLA's Neuropsychiatric Institute, he was involuntarily held for 72-hours for treatment. He credits this forced treatment with saving his life.

But be raises an interesting point about the barriers to treatment for the mentally ill. The limitations of healthcare associated with cost and insurance companies are clear. But what about barriers caused by the nature of one's sickness? 

Indeed, the very effects of mental illness may prevent a person from keeping up with their medications. Just a few skipped doses may cause a person to slip into an irreversible downward spiral, especially when a person in the midst of a vivid psychotic break (see above) refuses treatment.

Now I'm not advocating for a repeat of the Salem witch trials by any means, haphazardly pointing fingers and administering medication, but consider this analogy:

If a man with diabetes collapsed on the street, we'd hospitalize him and give him insulin. The civil rights issues involved with forced treatment of the mentally ill are real and shouldn't be downplayed. I can't speak to what's right for everyone. But I do know that for me, being involuntarily held at the hospital in 1999 allowed me to get back on my medication -- and may have saved my life.

Is there a happy medium for the treatment of homeless people with mental illnesses that refuse treatment? Can we honor their civil liberties while encouraging treatment that is potentially life-saving?

Does the Housing First approach (which provides the stability of having a home first followed by the delivery of social services) move us closer to helping homeless people afflicted with mental illness?