Ask patients to help heal themselves

By Robert Landauer – editorial columnist for The Oregonian, May 8, 1999. Not available elsewhere online.

Oregon is looking for ways to help mentally ill persons who are losing touch with reality but who spurn treatment and aren’t dangerous enough to be locked up.

The legal, ethical, financial and institutional issues are as tangled as a bird’s nest in a fishing reel after a bad cast.

Persons with chronic, serious, untreated mental illnesses make up 17 percent of the state’s prison population and about a third of the homeless. Intervention before they break laws or drift to the streets might ease the load of law-enforcement and social-service agencies. New-generation psychiatric drugs put heavy pressure on the Oregon Health Plan budget. Alternative approaches might reduce the need for these expensive neuraleptic medicines.

Mostly, though, families, psychiatrists and other mental-health workers, police, jailers and judges seek utmost wellness and maximum freedom for persons with mental illnesses. Oregon has been moving in that direction.

The rate of civil commitment — forced hospitalization of mentally ill people who have not broken the law but who judges say are dangerous to themselves or others — fell 50 percent between 1988-89 and 1998-99, says Barry S. Kast, administrator of Oregon’s Mental Health and Developmental Disability Services Division. There has been a 16 percent decline over the same period in the number of allegations of mental illness. So the commitment rate is decreasing much faster than the reports of illness.

The civil-commitment rate is not necessarily proof of the quality of the mental -health system, but it offers clues of where to look for more certain indicators. The availability of treatment for people with mental illnesses is one such area. During 1987-88 to 1997-98, the number of Oregon adults able to get mental -health treatment rose from 28,662 to 51,527. Provisions in Medicaid and the Oregon Health Plan to get earlier mental -health treatment for children doubled that treatment population from 10,951 to 23,377.

That’s a promising trend. The message, says Kast, is that people are getting into treatment earlier, and commitment usually is not necessary when that happens.

Still, service organizations estimate that 25 percent to 40 percent of the 5 million Americans with severe mental illnesses receive no therapy. Higher rates of homelessness, violence, incarceration and suicide follow.

“I think people don’t participate in treatment because they don’t like the menu,” says Cecelia Vergaretti of the Mental Health Association of Oregon.

Treatment of mental illness, then, is too serious to be left solely to the psychiatrists and mental -health agencies — or to civil libertarians with no personal, family or professional experience with the realities of mental illness.

It is an arrogant illusion that the mentally ill can’t make useful choices about their treatment.

Many of them can. Enlisting them as partners in shaping their treatment promises to be more productive than trying, for example, to force drugs on people who resent the imposition and, consequently, reject all help.

Oregon has an exciting opportunity to learn more about helping the mentally ill. The National Mental Health Consumers’ Self-Help Clearinghouse, aided by numerous Oregon and national co-sponsors, will conduct a National Summit of Mental Health Consumers and Survivors Aug. 25-29 in Portland. (Information toll-free at 1-800-553-4539, extension 297.) This is a prime chance to find out in detail what people with mental disabilities hope to see on treatment menus as well as information about what repels them.

Forced outpatient treatment has benefits in some cases. Its greatest drawbacks, though, are that it often doesn’t work and tends to stifle discussion of alternative approaches that might be more accepted and effective.

What we haven’t tried nearly enough is recruiting the patients to help them heal themselves. That’s what Oregon should do now.