Mental Health
This news story reminded me about a post I started a few weeks ago.
I have long believed that the existence and treatment of mental illness poses a tough political problem for libertarians generally (including the Civil Libertarians in the ACLU). I once attended a lecture given by Thomas Szasz; I could not accept his claim that mental illness is not really a disease. He claimed that it could not be legitimately called a disease since there was no cell pathology, e.g. no germ had been found to cause schizophrenia. Neither sickle cell anemia nor scurvy is caused by a foreign organism, so that doesn't seem to be the best argument to take. Furthermore, he seems to have fallen into Taleb's round trip error: "no germ found to cause disease" has become "no germs exist to cause the disease" [1]. However, he made a good case that the state has historically been given powers too broad for locking people up on the basis of insanity, for reasons that once included a wife's disobedience.
The problem as I see it with mental illness is that it is tough to construct a mechanism for treating the patient when the patient does not necessarily agree with either the prescription or the diagnosis. It seems easy to say that we should treat patients against their will when they are a danger to others, but what about when they are only a danger to themselves? Who gets to decide that? And on what basis? Is not a mortally obese person a danger to themselves? What about an extreme sport enthusiast? What about bicycle messengers? Abused, this could become a thin veneer for a state that wants to lock up the merely idiosynchratic. These people might include Howard Hughes, most physical science researchers (physicists), and Andy Kaufman. I'm afraid of its abuse by a government that already wants to assert broad powers for locking people up and holding them for indeterminate periods of time without a trial on the basis of secret evidence. [2]
The involuntary treatment solution is also known as Assisted Outpatient Treatment or AOT. The State of New York, among other places, has passed a form of this in Kendra's Law. Kendra's Law failed the gentlemen described in "Free to Die in Iowa" (Michael Judge, WSJ, 22 Dec 2007) (hattip: fashion-incubator) because the doctors apparently didn't know that they could have treated the man involuntarily. Kendra's Law is so-named for a girl killed by a man in the NYC subway. The man apparently had some limited access to treatment (199 treatments in two years and $95k in one year is hardly a lack of access), but he refused treatment on many occasions.
The primary advocate of Kendra's Law is a researcher by the name of Edward Fuller Torrey. Torrey is a former adviser to the National Alliance on Mental Illness (NAMI), an education and advocacy group. NAMI was founded in 1979 in the wake of the deinstitutionalization movement of the 1970s. NAMI advocates community treatment, a comprehensive approach involving the "consumer", their family and friends, civil authorities, medical professionals, and other orgranizations.
The deinstitutionalization movement started in the 1950s and 1960s, and achieved success in the 1970s. The Community Mental Health Act (CMHA) of 1963 is said to be a significant milestone in the history of the movement, though it isn't clear whether the measure was taken to address concerns for the rights of patients or for fiscal reasons (probably both). Another significant event in the history of the movement was the success of the book and subsequent movie, One Flew Over the Cuckoo's Nest. The movement has elements of Post Modernist Michel Foucault's thoughts on the cultural and social meaning of "sanity" as well as ACLU opposition to involuntary incarceration and the anti-psychiatry movement. The anti-psychiatry movement itself is fueled in part by Scientology and in part by legitimate recognition of some of its shortcomings, such as the fact that homosexuality was listed as a mental illness by the American Psychiatry Association as recently as 1974. More recently, the finding of increasing numbers of children to have ADHD in order to control their behavior with Ritalin seems to have some merit as legitimate criticism. Additionally, it is noted that many clinicians are also stakeholders in pharmaceutical interests.
I think that much of the thinking that goes into this subject is too simplistic. In part, this may be because the entire debate is locked up on the left end of the political spectrum between those who have never met a federal program they didn't like and those who don't believe the state should ever have a police function. There is broad overlap with the former group and socialists, and between the latter group and libertarians. I'm skeptical of both. [3] At the other end of the spectrum, we frequently find people like Michael Medved ranting about the injustice of failing to lock up everyone who poses a danger to anyone without any apparent consideration of whether jail is the appropriate environment for people whose main problem is bad genetic luck.
What are the meta problems?
- Who will watch the watchers?
- How do you take politics out of defining what "risk to oneself" means?
- Where do you draw the line on risk to oneself? 1%? 10%? Imminent danger? Isn't the latter the most obvious category, and one that is mainly detected too late no matter how much we spend on the problem?
- Can we recognize that we are talking about locking people up, but we simply aren't calling it jail? We can call it a hospital, but that doesn't mean it is any less oppressive than jail. The patients are still at the mercy of the staff and to a large extent other patients.
I have very little problem with funding mental health initiatives. As usual, I would rather see it done at the private, then the local, then the state level, but not at the federal level at all.
To some extent, this is exactly what is happening. NAMI is private. The local chapter of NAMI has obtained some sponsorship of temporary communal living quarters. That has been augmented with City and State funding. I think it is underfunded, but that should only drive the creativity of the advocates that much harder (isn't this what they say when they advocate unfunded mandates on various industries?)
We also know that action in the private sphere is moving faster than in the public sphere, due in part to consumers who are demanding more of their employer-sponsored health packages. "During the past three decades, per enrollee spending for a common benefit package has grown at a slightly slower average annual rate for Medicare than for private health insurance," according to this. To be sure, this doesn't help people who are unemployed, but it does help those teenagers whose parents are employed and insured to get early treatment, keeping them off the public programs.
The money is spent on doctors, nurses, support staff, facilities, and medication. Not as much money is required if stabilization can be achieved quickly. That means having a very effective, broad program that directs people into the system quickly.
I doubt social medicine works any better on this score. Homelessness and schizophrenia are significant problems in both Europe and Canada. Recall the recent riots in the Netherlands as homeless people were evicted from squatting in abandoned buildings? Or the recent problems with moving the homeless in Paris?
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[1] E. Fuller Torrey has been looking at the possibility that a parasite found in cat feces may have something to do with schizophrenia.
[2] And if you think secret evidence and holding people without trials started with George W., I have a bridge to sell you. The Clinton Administration also locked up foreign suspects without trial on the basis of secret evidence (see, for example, this article). I doubt this problem started in the 1990s, either. In fact, Wilson's Palmer Raids come to mind.
[3] I am reminded of the claims that Ronald Reagan is primarily responsible and the Republican party partially responsible for the lack of mental health care in the United States. This claim is due to the fact that Reagan happened to sign an 1981 Omnibus Budget Reconciliation Act that repealed another law, National Mental Health Systems Act of 1980, that had never gone into effect. In fact, that 1980 Law would have reduced federal expenditures on mental health care. In addition, the 1981 Omnibus bill kept the cuts, but "converted them to block grants disbursed with few strings attached. New York State, which used block-grant monies to fund community-based programs, and other states [had] to cut mental health programs." The issue then was not that the Reagan Administration was cutting funding for these programs, but more specifically, they were cutting some funding and then cutting the strings attached to that funding. The local authorities were given broad powers to use the money, and apparently failed to direct it to mental health. The blame for that failure should fall on the entire spectrum, from left to right, but it doesn't.
I think any reasonable person could conclude that Reagan's involvement was incidental since the deinstitutionalization movement preceded him, guided Congressional action on the 1963, 1980, and 1981 Acts, and led to the founding of NAMI, and that furthermore nobody has come along since and proposed replacement legislation at either the state or the federal level despite the fact that Democrats occupied the White House for 8 years and controlled Congress for 15. It seems apparent to me that there is broad recognition of the problems laid out at the beginning of this piece: that involuntary treatment of adults is a difficult problem with no easy solutions.
The problem as I see it with mental illness is that it is tough to construct a mechanism for treating the patient when the patient does not necessarily agree with either the prescription or the diagnosis. It seems easy to say that we should treat patients against their will when they are a danger to others, but what about when they are only a danger to themselves? Who gets to decide that? And on what basis? Is not a mortally obese person a danger to themselves? What about an extreme sport enthusiast? What about bicycle messengers? Abused, this could become a thin veneer for a state that wants to lock up the merely idiosynchratic. These people might include Howard Hughes, most physical science researchers (physicists), and Andy Kaufman. I'm afraid of its abuse by a government that already wants to assert broad powers for locking people up and holding them for indeterminate periods of time without a trial on the basis of secret evidence. [2]
The involuntary treatment solution is also known as Assisted Outpatient Treatment or AOT. The State of New York, among other places, has passed a form of this in Kendra's Law. Kendra's Law failed the gentlemen described in "Free to Die in Iowa" (Michael Judge, WSJ, 22 Dec 2007) (hattip: fashion-incubator) because the doctors apparently didn't know that they could have treated the man involuntarily. Kendra's Law is so-named for a girl killed by a man in the NYC subway. The man apparently had some limited access to treatment (199 treatments in two years and $95k in one year is hardly a lack of access), but he refused treatment on many occasions.
The primary advocate of Kendra's Law is a researcher by the name of Edward Fuller Torrey. Torrey is a former adviser to the National Alliance on Mental Illness (NAMI), an education and advocacy group. NAMI was founded in 1979 in the wake of the deinstitutionalization movement of the 1970s. NAMI advocates community treatment, a comprehensive approach involving the "consumer", their family and friends, civil authorities, medical professionals, and other orgranizations.
The deinstitutionalization movement started in the 1950s and 1960s, and achieved success in the 1970s. The Community Mental Health Act (CMHA) of 1963 is said to be a significant milestone in the history of the movement, though it isn't clear whether the measure was taken to address concerns for the rights of patients or for fiscal reasons (probably both). Another significant event in the history of the movement was the success of the book and subsequent movie, One Flew Over the Cuckoo's Nest. The movement has elements of Post Modernist Michel Foucault's thoughts on the cultural and social meaning of "sanity" as well as ACLU opposition to involuntary incarceration and the anti-psychiatry movement. The anti-psychiatry movement itself is fueled in part by Scientology and in part by legitimate recognition of some of its shortcomings, such as the fact that homosexuality was listed as a mental illness by the American Psychiatry Association as recently as 1974. More recently, the finding of increasing numbers of children to have ADHD in order to control their behavior with Ritalin seems to have some merit as legitimate criticism. Additionally, it is noted that many clinicians are also stakeholders in pharmaceutical interests.
I think that much of the thinking that goes into this subject is too simplistic. In part, this may be because the entire debate is locked up on the left end of the political spectrum between those who have never met a federal program they didn't like and those who don't believe the state should ever have a police function. There is broad overlap with the former group and socialists, and between the latter group and libertarians. I'm skeptical of both. [3] At the other end of the spectrum, we frequently find people like Michael Medved ranting about the injustice of failing to lock up everyone who poses a danger to anyone without any apparent consideration of whether jail is the appropriate environment for people whose main problem is bad genetic luck.
What are the meta problems?
- Who will watch the watchers?
- How do you take politics out of defining what "risk to oneself" means?
- Where do you draw the line on risk to oneself? 1%? 10%? Imminent danger? Isn't the latter the most obvious category, and one that is mainly detected too late no matter how much we spend on the problem?
- Can we recognize that we are talking about locking people up, but we simply aren't calling it jail? We can call it a hospital, but that doesn't mean it is any less oppressive than jail. The patients are still at the mercy of the staff and to a large extent other patients.
I have very little problem with funding mental health initiatives. As usual, I would rather see it done at the private, then the local, then the state level, but not at the federal level at all.
To some extent, this is exactly what is happening. NAMI is private. The local chapter of NAMI has obtained some sponsorship of temporary communal living quarters. That has been augmented with City and State funding. I think it is underfunded, but that should only drive the creativity of the advocates that much harder (isn't this what they say when they advocate unfunded mandates on various industries?)
We also know that action in the private sphere is moving faster than in the public sphere, due in part to consumers who are demanding more of their employer-sponsored health packages. "During the past three decades, per enrollee spending for a common benefit package has grown at a slightly slower average annual rate for Medicare than for private health insurance," according to this. To be sure, this doesn't help people who are unemployed, but it does help those teenagers whose parents are employed and insured to get early treatment, keeping them off the public programs.
The money is spent on doctors, nurses, support staff, facilities, and medication. Not as much money is required if stabilization can be achieved quickly. That means having a very effective, broad program that directs people into the system quickly.
I doubt social medicine works any better on this score. Homelessness and schizophrenia are significant problems in both Europe and Canada. Recall the recent riots in the Netherlands as homeless people were evicted from squatting in abandoned buildings? Or the recent problems with moving the homeless in Paris?
-----------------------------------------------------------
[1] E. Fuller Torrey has been looking at the possibility that a parasite found in cat feces may have something to do with schizophrenia.
[2] And if you think secret evidence and holding people without trials started with George W., I have a bridge to sell you. The Clinton Administration also locked up foreign suspects without trial on the basis of secret evidence (see, for example, this article). I doubt this problem started in the 1990s, either. In fact, Wilson's Palmer Raids come to mind.
[3] I am reminded of the claims that Ronald Reagan is primarily responsible and the Republican party partially responsible for the lack of mental health care in the United States. This claim is due to the fact that Reagan happened to sign an 1981 Omnibus Budget Reconciliation Act that repealed another law, National Mental Health Systems Act of 1980, that had never gone into effect. In fact, that 1980 Law would have reduced federal expenditures on mental health care. In addition, the 1981 Omnibus bill kept the cuts, but "converted them to block grants disbursed with few strings attached. New York State, which used block-grant monies to fund community-based programs, and other states [had] to cut mental health programs." The issue then was not that the Reagan Administration was cutting funding for these programs, but more specifically, they were cutting some funding and then cutting the strings attached to that funding. The local authorities were given broad powers to use the money, and apparently failed to direct it to mental health. The blame for that failure should fall on the entire spectrum, from left to right, but it doesn't.
I think any reasonable person could conclude that Reagan's involvement was incidental since the deinstitutionalization movement preceded him, guided Congressional action on the 1963, 1980, and 1981 Acts, and led to the founding of NAMI, and that furthermore nobody has come along since and proposed replacement legislation at either the state or the federal level despite the fact that Democrats occupied the White House for 8 years and controlled Congress for 15. It seems apparent to me that there is broad recognition of the problems laid out at the beginning of this piece: that involuntary treatment of adults is a difficult problem with no easy solutions.
Labels: health-care, libertarian, philosophy, police-state
