Our class only read part of chapter 17 of Butcher’s Abnormal Psychology: a section about inpatient mental health treatment in contemporary society and another about controversial legal issues and the mentally ill.
Mental health treatment in contemporary society
In the late 19th century, mental hospitals were filled with patients. Many of these patients lived in a horrific environment that was unhealthy both physically and mentally. In those hospitals that had humane treatment of patients, there was a concern that patients would get “institutional syndrome” – in which people lost their ability to socialize and live independently because they had been in a mental hospital for so long.
In the mid-to-late 20th century, a movement to deinstitutionalize the mentally ill gained momentum. It began in the 1950s and 60s, when antipsychotic drugs were developed. These medications made it possible for patients to leave hospitals and live independent lives. Later, a desire to rescue people from inhumane environments and to keep them from getting “institutional syndrome” accelerated the rate of deinstitutionalization. Another consideration in deinstitutionalization was the desire to decrease medical expenditures. As mentioned in my earlier post on Chapter 2, deinstitutionalization was detrimental to many mentally ill people. One third of the homeless population is comprised of mentally ill people, and a horrifying number of the mentally ill are incarcerated with little to no mental health treatment (which, by the way, means that society is still doling out the bucks to pay for the housing of mentally ill).
In contemporary American society, if a person is unable to care for himself, or if he is a danger to himself or others, he can be placed in a psychiatric hospital. Such a commitment can be voluntary, but if someone is considered a danger to himself or society and he refuses hospitalization, civil commitment procedures can be undertaken, and he can be confined involuntarily in a mental hospital.
Such hospitals generally combine traditional forms of therapy with a constructive social environment. A study in 1977 by Gordon L. Paul and Robert L. Lentz compared the relative effectiveness of three treatment approaches.
Milieu therapy, which focuses on providing the patient with a very clear idea of what the staff expectations are and providing feedback about compliance with those expectations, encouraging the patients to be active in their own treatment decisions, and providing social groups for support and “positive” peer pressure.
Social-learning, in which the patients learn socially acceptable behavior through a token economy (they get tokens when they behave well). With tokens, the patients can buy privileges.
Traditional treatments, with pharmacotherapy, occupational therapy, and individual group therapy. For instance, a friend of mine was recently released from a mental health ward which had psychological therapy, psychiatry, yoga, prayer meetings, knitting classes, and all sorts of social groups.
Paul and Lentz studied 28 schizophrenic patients for resocialization, learning new roles, and reducing bizarre behavior. From the social learning program, 90 percent of the patients remained in the community after release; compared to the 70 percent who’d had milieu therapy, and the less than 50 percent who’d had traditional therapy. I haven’t read it, but there’s a review of Paul and Lentz’s study available here.
All of these programs seem like a positive change from the early 20th century, but in order to voluntarily get into one of these hospitals, the patient must have both resources and mindfulness of illness. In order to get involuntarily committed, the patient must have an advocate willing to report his danger. Most of the homeless do not have such advocates, and thus they slip between the cracks.
Controversial legal issues and the mentally ill
In recent years news reports have sensationalized grizzly murders committed by sociopaths and psychotic people. In fact, one such grizzly murder was just discovered in the Twin Cities (where I live). It’s easy to say that if only the mental health system were better, we could prevent such tragedies. But how do you really know when someone is dangerous before they actually do anything? A mental health professional is authorized to make such a judgement call, though the dangerous person must first be seeing a mental health professional before any judgement can be made. And often a patient gives no hint of his violent thoughts.
If the patient does give a hint of violent thoughts, the mental health worker (or even a priest during confession), has the duty to report the dangerous individual to the authorities, and in some states to warn the individual who has been threatened.
One huge controversy about dangerous mentally ill people is the insanity defense (or not guilty by reason of insanity, NGRI). Someone can be successful with this plea if he is thought to not know right from wrong or if he was compelled irresistibly to perform the violent act. The defense attorney must obtain the testimony of a mental health professional who convincingly claims that the accused was insane at the time of the crime.
Because it is very difficult to be acquitted as NGRI some people plea “guilty but mentally ill (GBMI).” With success of this plea, the convicted would be found guilty but placed in a mental institution instead of a prison. Many hope that this plea will decrease the number of patients who are found not guilty by reason of insanity, are confined to a mental institution, soon judged to be in recovery, and are unconditionally released into society. When a person is found guilty but mentally ill, he remains for his entire sentence in the mental institution.
A third way that a mentally ill person can protect himself from unethical treatment is to claim incompetence to stand trial. If a person is charged with a crime but is unable to understand the proceedings due to mental health, he can postpone the trial until they have recovered sufficiently to understand. Such people can be hospitalized until they are deemed competent.
An interesting point that the authors brought up was about patients diagnosed with disassociative identity disorder, DID – formerly known as multiple personality disorder. If one personality commits a crime, is it ethical to punish all personalities? This is a question that first occurred to me several years ago while reading A Fractured Mind, by Robert B. Oxnam. Oxnam gave a few examples of when one personality did something “wrong,” and Oxnam implied that he, himself, was not guilty of those transgressions, because it was his other self that committed them. The two examples I remember are when one of his personalities cheated on his wife and when one of his personalities stole a bunch of stuff from a boating store. It peeved me that Oxnam thought it was ok to brush off those acts by saying “the other (bad) me did it.” But perhaps that is because I’m skeptical of true multiple personalities that are unaware of, and unable to control, the others’ actions. If it does exist, I’m sure it’s very, very rare.
On the other hand, I do know someone who has disassociative episodes and was caught doing something illicit during an episode. But my friend has never blamed the “other” guy – he seems quite willing to step up and take the blame. Somehow that willingness to accept the blame makes him seem less culpable, in my eyes, than Oxnam.
What do you think? Do you believe that people with DID can have completely separate identities that are unaware of, and unable to control, each others’ actions? Do you think the entire set of identities should be punished if one personality commits a crime?
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