Care in the Community

By Legal Eagle

A friend of mine is anorexic, and over the last few years, she has become very unwell. I was so concerned that I spoke with her parents a while back. “There’s nothing we can do,” they said with despair. “She’s an adult. We can’t force her to seek treatment. We have tried everything we can and exhausted every avenue.” I have also tried to help my friend, but with limited success. The desire to help oneself must come from within; otherwise, no matter how much help and support you give, your efforts are fruitless. All I can do is make it clear that I am there for her when she decides that she needs me and wants to do something about it. I had other anorexic friends during high school who came out the other side, and now live happy, healthy lives, so all I can do is hope that she will also be able to do so too.

What do you do with people who are so mentally ill that they harm themselves and others? In the last few decades, there has been a tendency towards deinstitutionalisation and “care in the community”. “Care in the community” has two motivators. On the one hand, people with psychiatric problems are encouraged to live normal lives within the community, instead of being incarcerated in an asylum. The other (less noble) motivation is to enable government to save the costs of having to staff and fund mental institutions by keeping people in the community instead.

While I support the idea that people should be able to live a normal life where possible, all too often “care in the community” becomes “out of sight, out of mind”. Although it is hard to get statistics, it appears that a very high proportion of homeless people have psychiatric problems: far more than in the general population. This study suggests that 75% of homeless people in Sydney have a mental illness, as opposed to 20% in the general population, and that this is in some ways linked to deinstitutionalisation. It is a “chicken and egg” situation: homelessness and poverty can cause mental illness, but by the same token, mental illness can cause homelessness.

There is also a natural concern that people’s psychiatric records should be private. A 1996 study by the British Mental Health Charity, MIND, found that many people with psychiatric problems had suffered from significant discrimination in the workplace, in parenting and in the community generally once their psychiatric problems became common knowledge. This doesn’t surprise me. As I have discussed in this blog before, depression is a big unspoken problem in the legal industry (more than in almost any other industry). Statistics show that lawyers are 3.6 times more likely than non-lawyers to suffer from depression and other mental illnesses. But does anyone ever talk about it openly? No way. If you raise the issue in the workplace, then people start to doubt your ability to cope, and suspect that you might “go mad” again at any moment. One woman I know mentioned her mental health problems to her workmates, and was then discriminated against in a most appalling manner…which, ironically and terribly, caused her to fall into a deep depression.

What to do, then, when a friend, a colleague or an acquaintance displays signs which tend to show that he or she is mentally ill and in need of psychiatric assistance? These questions have come into prominence again with the Virginia Tech shootings, as it has become evident that Cho Seung-Hui had a documented history of mental health problems, and displayed signs that he was a risk to himself and others. University officials, students, lecturers and the police all knew that he had problems, but there was very little that they could do about it. As this New York Times article discusses, Federal privacy and antidiscrimination laws restrict the ways in which universities can deal with students who have mental health problems. The article says:

Universities can find themselves in a double bind. On the one hand, they may be liable if they fail to prevent a suicide or murder. After the death in 2000 of Elizabeth H. Shin, a student at the Massachusetts Institute of Technology who had written several suicide notes and used the university counseling service before setting herself on fire, the Massachusetts Superior Court allowed her parents, who had not been told of her deterioration, to sue administrators for $27.7 million. The case was settled for an undisclosed amount.

On the other hand, universities may be held liable if they do take action to remove a potentially suicidal student. In August, the City University of New York agreed to pay $65,000 to a student who sued after being barred from her dormitory room at Hunter College because she was hospitalized after a suicide attempt.

Also last year, George Washington University reached a confidential settlement in a case charging that it had violated antidiscrimination laws by suspending Jordan Nott, a student who had sought hospitalization for depression.

There is a difficult balance. Just because someone is suicidal, or suffers from a mental illness, does not mean that they should be prevented from attending university (or work). It is possible to overcome mental illness and psychiatric problems, and a past history of including problems should not be held against a person for life. However, there should definitely be better processes for identifying problems, for keeping tabs on vulnerable people and for treating the mentally ill.

There seems to be a serious deficiency in the way in which even highly developed countries such as Australia and America deal with mental health issues. Patrick McGorry, a Professor of Psychiatry at the University of Melbourne has said:

When a young person experiencing an acute asthma attack goes to see a doctor, they can be guaranteed an almost immediate response. When a woman notices a breast lump and seeks a diagnosis and treatment, it is readily available. When a middle-aged man experiences chest pain and calls the ambulance, he gains immediate access to high-quality care. Everyone accepts that a rapid response, early diagnosis and expert treatment can save lives and prevent disability.

What about the 22-year-old with depression who deliberately harms themselves? The Not for Service report (Mental Health Council of Australia, Brain and Mind Research Institute and Human Rights and Equal Opportunity Commission) shows the situation for mental disorders is totally different. Why? Serious funding constraints force mental health services to provide little more than palliative care. Treatment has to be rationed until it can be withheld no longer.

Despite the best efforts of many dedicated clinicians, there is a vast and unnecessary gap between the quality and coverage provided for general medical illnesses and psychiatric illnesses, which leads to Third World outcomes in a First World country

In the report cited above, Not for Service, a parent said:

Regarding ‘involuntary intervention’; although the Mental Health System espouses ‘early intervention’ and carers are encouraged to practice this, the constraints surrounding ‘involuntary intervention’ can make ‘early intervention’ impossible. From personal experience, it means that intervention will not be carried out without the consumer’s consent until that person is acutely unwell and a ‘crisis situation’ arises. Although it will then, still be without the consumer’s consent, probably even more so, and will probably mean a more forceful intervention, somehow this policy is considered more humane…As ridiculous as it sounds, it means that the behaviour of the unwell person has to disturb, alarm or frighten a member of the public enough to bring it to the attention of the police or the Mental Health Service – a carer’s word that the person is at risk is not enough…and we talk about reducing the stigma of mental illness.

(Submission No. 178)

Another parent said:

After exhibiting psychotic behaviour my son spent 21 days (detained) in Glenside Hospital in March 2002. He was counselled and medicated then turned out into the community with some medication but no follow up care. Shortly afterwards he stopped his medication, reverted to his anti-social, aggressive and irrational behaviour, a state he has been in unchecked for two years.

(Submission No. 11)

Even where a patient voluntarily seeks psychiatric help, they may be unable to get adequate help. But what if someone is so unwell that they cannot appreciate the depth of their illness? Should they be involuntarily admitted to a mental institution? The situation seems to be that involuntary admission will only be contemplated once a mentally ill person seriously harms himself or another. Such situations are rare but unfortunate, as they only increase the stigma towards the mentally ill in general.

Obviously, reopening asylums is not the answer. But there must be a better answer than letting seriously ill people go without treatment before they harm themselves or others. I think schools, universities and workplaces should have guidelines as to when it is appropriate to intervene, and some way of dealing with mentally ill people which does not stigmatise and marginalise them but allows them to be properly treated. There needs to be law reform and policy reform which makes it clear to universities, schools and workplaces what procedures should be followed.


  1. Anonymous
    Posted April 21, 2007 at 2:30 pm | Permalink

    I think the issue is not how we deal with people with a mental illness but how we offer support.

    Unless there is a profit to be made or a performance pay regime to implement it seems as a community we look the other way.

    Case workers in mental illness are grossly overworked and underpaid. Many people with mental illness require the consistency and certainty that a regular caseworker brings but too often the workers burn out, leave and the continuity of care is lost.

  2. Legal Eagle
    Posted April 21, 2007 at 11:08 pm | Permalink

    Dear Anonymous @ 1:25pm,

    I agree. I would say carers for the mentally ill, the disabled, the ill and the elderly are all undervalued, over-worked and underpaid. Our society just doesn’t value professions which care for others – it’s all about the bottom line.

    In my post, I was not suggesting that case workers do not care. Rather I suggest that there are simply not enough resources for everyone to be cared for adequately.

  3. LDU
    Posted April 22, 2007 at 6:08 pm | Permalink

    Adolf Hitler used to have physicians conduct a variety of experiments on people thought to be mentally ill. One such experiment was injecting some chemical in their eye hoping it would turn blue.

  4. cherry ripe
    Posted April 23, 2007 at 4:39 pm | Permalink

    It seems to me that the essential problem with mental health treatment is that of consent. Where a person is diagnosed with any other life-threatening illness, they usually fully consent to treatment – or at least exercise consent in a judicious way according to their strongly held principles.

    But what if a person is so sick that they are incapable of rational consenting behaviour? First, how do you determine this? Second, how do you respond? This seems to me to be the crux of the problem with mental illness treatment.

    Many will voluntarily admit themselves – in these cases the only issue is one of capacity of available facilities.

    However, it’s those who refuse treatment, who may well be hell-bent on self-destruction that pose a real problem: how can we assess their rationality? Does a person have a right to self-destruct? Do we have a right to stop them and in what circumstances?

    These are the fundamental questions that are contemplated regularly by policy makers in the field, and it’s exactly what makes the area so difficult to deal with.

    It reminds me of the conundrum that was posed by a famous death penalty case in the USA. An inmate on death row had decided that he was sick of the lengthy, agonising appeals process, and decided that he would rather die than suffer through the tortuous doubt any further. So he told his legal advisors to cease all appeals and accept the death penalty. At that point, the corrections department determined that he could not possibly be acting rationally: he must be suicidal. So he was removed from death row and treated for depression so that he might resume the appeals process and return to death row for a further number of years. Apparently he could only be put to death as long as he didn’t want to die – as soon as he did want to die, the State had no mandate to kill him!

    The idea of a “right to suicide” might be controversial, but it may be worth thinking of it as a person’s ultimate right, in the context of suffering all types of pain. As long as we’ve done our best, and cared our best – another question for government and society – there may be little we can do.

  5. Legal Eagle
    Posted April 23, 2007 at 6:34 pm | Permalink

    Very perceptive comment, Cherry Ripe! I think you have really drilled down to the essence of the difficulty surrounding mental illness: where the illness affects a person’s judgment, it is hard to gain consent to treatment.

    I’ve missed your comments – although I guess you’ve got more important things on your mind right now – like creating a new little person! Hope you are well.

Post a Comment

Your email is never published nor shared. Required fields are marked *