Adam Blatner

In the early 1970s a major shift occurred politically regarding the status of the acute and chronically severely mentally ill—especially those with active uncontrolled schizophrenia or active bipolar illness. Many were responding to the medications they were given in the hospital, becoming more stable, so it seemed that it was unnecessary to keep them in major state hospitals when they could be maintained in small group homes and they’d come into the clinic for their medication checks.

But there was a catch: A significant percentage of these people had an interesting and not-widely-appreciated feature of their mental illness: anosognosia. It’s sort of an ultra-denial syndrome. They don’t feel “sick,” and don’t perceive that there’s anything wrong with their thinking, so why should they take medicines that make them feel funny or sick? So a lot of them dropped out of the clinic, and some became homeless, or just wouldn’t stay in a special residence.  (Some patients do recognize their disorder and are conscientious about accepting responsibility for their disability. And many of these, stable on medicine, can live variably medium-to-higher functioning lives.)

There’s another catch: Some people are hospitalized against their will longer than they need to be, or they don’t really pose a danger, so patients’ rights advocates have good reasons for wanting treatment to be limited only to that which is necessary and involves the least restrictive force. There was indeed too much involuntary hospitalization and treatment for questionable reasons before the last third of the century, and occasionally still today. (Thomas Szasz has been a pioneer or cassandra about this—to the point of denying that mental illness even exists. Others, such as Scientologists, also carry this banner.) On the whole, though, the pendulum may have swung too far in the other direction, and when patients go off their medicines and the family gets frantic, it is often extremely difficult to get mental health care for these people. Some become truly dangerous. In a recent Texas Monthly article, a few patients are described who, because of their fierce threatening ended up being shot and killed. That community is trying to get a special program, but many other communities offer woefully inadequate care.

Many of the severely mentally ill end up in involuntary situations—jail—where their disease leaves the vulnerable to other predatory prisoners, or likely to over-react and hurt other prisoners, and so forth. The problem is that fuzzy area between those who know they’re sick and accept the sick role, accept that they need to take their medicines; and those who are in denial. (A particularly poignant story is told by a bright woman who suffered a number of relapses before she finally found medicines she’d be willing to take—this is in the touching actual memoir titled The Center Cannot Hold.)

Then there’s the general political situation that marginalizes the least influential constituents—and the mentally ill and their families tend to fall into that slot. (Marginalization is a good word, describing the discounting of certain groups, individuals, problems, as if they were an afterthought, insignificant, on the margins. For example, it might fairly be said that Hollywood marginalized people of color as significant players in movies during the early-mid 20th century.)
So there’s a conflict today about how to deal with this problem. Some are seen as being too rabid in the support of families of the mentally ill; how to raise consciousness so that there is much better funding for the care of these people without stigmatizing the disease, because the vast majority of these patients don’t actually become dangerous. As the King of Siam (in the Broadway musical, Anna & the King, mid-1950s) said, “Is a puzzlement.”  This blog then is intended to note in a more balanced way the difficulties of this socio-political “hot potato.”