How do we treat the severely mentally ill?

Brilliant teachers can change your life. I became fascinated with mental illness in college when I took a course in psychopathology from a legend. He was the only living person with a building on campus named after him. An eminent psychologist, he had been dean of the university, retired from that and went back to his first love – teaching. His lectures were engaging. His connections were unparalleled.

A very expensive, world famous private psychiatric hospital is located just north of the college campus. Our professor arranged for us to go in small groups and observe clinicians interviewing people with major psychotic mental disorders – bipolar, paranoid schizophrenia, true paranoia, and others. We watched, listened, engaged with, and asked questions to both psychiatrists and their patients. Later, our professor debriefed us, told us what he observed, including what he felt the clinicians had done poorly.

I got married at a very young age and needed a job while I was in college to support two babies and a wife. My mother knew someone who worked in the famous hospital I just mentioned, and, through that connection, I got an interview and a job as a psychiatric aide. With one other more experienced aide, I worked from 4 to midnight on an all-male, locked ward where the sickest of the psychiatric patients were treated.

And they were in fact treated. This was not a warehouse state hospital. No lobotomies. It wasn’t One Flew Over the Coocoo’s Nest. This was a highly respectable hospital that provided individual and group therapy, art therapy, recreational therapy, and many other programs. The campus is huge and beautiful – rolling green hills, mature trees. The staff was (and I presume still is) highly trained. The average stay was a little over a year. Patients were released with support systems like transitional housing and job training in place.

I had another professor, also quite brilliant, who was considered a leading expert on Shakespearean tragedy. He too gave fascinating lectures. He was schizophrenic. Every few years, he would deteriorate, have frequent auditory and visual hallucinations, and lose touch with reality. During those times, he would be admitted to the hospital where I worked, and spend 4 to 6 months getting tuned up to go back to work.

This particular hospital worked as well as any, better than most, in treating severe mental illness. But it only worked for those with extraordinary health insurance or extraordinary wealth.

And, it worked because those were the days before the civil rights patient advocate movement. That movement meant well. People who cared saw how the mentally ill were treated in aging, overcrowded, understaffed state hospitals where shock treatments and lobotomies were used as behavior control. They advocated for humane treatment and pushed to all but abolish involuntary commitment.

As a result, it is only possible to involuntarily hold a mentally ill person if they are an active threat to themselves or others. Even then, holding them for more than 72 hours is difficult. No one wants to go back to the days when a husband could have his wife committed with a phone call. And, no one wants to return to a time when patients were simply warehoused out of sight.

I am all for autonomy. But perhaps we have carried autonomy to an extreme. A person lying on the sidewalk bleeding needs to be in a hospital as quickly as possible. Similarly, if a fellow human being is severely mentally ill, has lost touched with reality, is actively hallucinating and deeply deluded, the compassionate response, the loving response, ought to be to admit them to a facility like the one I worked in, whether they agree or not, and hold them there, giving them psychological and pharmacological treatment until they can safely be released to a half-way house where their medication is monitored and life skills are taught. With ongoing out-patient therapy and medication, many, perhaps most, severely mentally ill people can be integrated into society and live meaningful lives.

The alternative is tragic for all of us.