Let’s do a thought experiment. Imagine that a person you love is driving on a mountain road. You’re watching from above, maybe from a helicopter. The road they’re driving on is unusual—it has tall walls on both sides, so your loved one can’t see the terrain. Suddenly, they begin driving faster and faster, which makes you nervous given how windy the road is. You glance ahead and see that around the next bend the road plunges off a cliff.
In other words, you are watching your loved one speed toward disaster, and you can’t do anything to help.
This terror captures what happens when a serious mental illness (SMI) strikes your family. In some cases, like ours, the attack is sudden and jarring. In others, the illness progresses over a longer period of time, with behavior becoming gradually more bizarre. But in each case, as your loved one moves closer toward the cliff, you feel more and more helpless.
“Leave us helpless, helpless, helpless." -- Crosby, Still, Nash & Young
Why feel helpless, you ask? First, you must understand that acute psychosis accompanies the worst psychiatric diseases. Psychosis means that your thoughts are not based in reality. You begin believing, hearing or seeing things that are not actually happening. However, given that your brain is processing all this information as real, you wholeheartedly believe it. Second, one of the most common symptoms of SMI is anosognosia. This is a just a medical term meaning that someone can’t recognize that he or she is sick. It makes perfect sense given that the brain is the organ that has been compromised. Combine these two factors, and it’s easy to see why very few people suffering SMI actually seek out treatment on their own.
Instead, their illness progresses, and their thoughts and actions become more disconnected. Watching someone experience this is incredibly distressing. You desperately want to do something, but when you reach out to help, trying to prevent the impending crisis, you realize how little power you have. You can’t force your loved one into treatment; you can’t force them to take medication; you can’t force them to see a psychiatrist. And, unless they meet one of three criteria, no one else can, either.
For someone to be committed for treatment against their will one of the following criteria must be met: (i) they are an imminent threat to themselves, (ii) they are an imminent threat to others, or (iii) they are unable to meet the basic needs of survival (food, lodging, hygiene, etc.). In reality, the last one is so problematic that it is almost never considered. But the first two are also difficult. How can you tell if someone is an “imminent threat?”
“Do you really want to hurt me?" -- Culture Club
In most cases, a psychiatrist or first responder makes the imminent threat determination. But here’s where things break down. First, many psychotic people can be amazingly coherent even when suffering delusions and hallucinations. They can sound and act fine when interacting with others, especially for short periods of time. Second, HIPPA laws, or the privacy rules that surround medical issues, scare people into keeping family members at a distance. So, those who really know what’s going on are often not consulted.
All of this plays out against a backdrop of laws and policies designed to protect civil liberties. This is understandable; if we’re giving the state the ability to confine people against their will, we need to set a high bar. That’s a slope no one wants the government slipping down, especially given the unfortunate long-term asylums of the past. For this reason, those making decisions regarding involuntary commitment usually err on the side of maintaining a person’s freedom. Or, in the case of many police officers, they aren’t trained to recognize or deal with SMI. And, frequently, they are responding after a law has already been broken.
The sad result is that in this country someone must essentially (i) commit a crime, (ii) hurt themselves or (iii) hurt someone else before they can be forced into treatment. And too often, instead of ending up in a place that can actually help, the sick person winds up in jail or prison or worse. Too many heartrending cases exist that underscore this reality. One of the most powerful advocates for change is Jerri Clark. Instead of receiving the treatment her son Calvin so desperately needed, he was repeatedly arrested, imprisoned, and then released without notice, alone and sick, until he succumbed to his illness.
Some middle ground has to be found. When sick people lack decision-making capacity, medical personnel have the ability to make decisions for them. When an unconscious victim of a car accident comes into the emergency room, doctors don’t wait to see if treatment is wanted; they operate. Likewise, if someone is suffering from SMI, they require psychiatric support immediately. They need a safe place, constant monitoring, and medication.
The bottom line is that family members must be brought into the process early, even after the age of 18, and given some power over the situation. Decisions should be made with as much information from trusted sources as possible, and no one is better informed than those close to the sufferer. As advocate Doris A. Fuller, whose daughter was a victim of the current system, stated in a testimony before the Federal Commission on School Safety:
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