On mental illness and the Right Reverend

While most folks have the day off to celebrate (do we, really?) Dr. Martin Luther King, Jr.'s birthday, I am at the office along with a number of multi-colored employees tending to the needs of our mentally ill residents. I'd like to imagine that he would have appreciated how far we've come to help these disenfranchised citizens. Race relations among the clients are pretty good. Nobody has called another a "white devil" or some other racial epithet in a few months now. This climate probably has to do with the fact that a few severely paranoid delusional tenants are in the hospital at the moment. "Oh, he's getting a tune-up," many clients will say. They smile when they say that, most of them having had long-term stays in psychiatric hospitals themselves.

But balancing the rights of the mentally ill with the needs of society is very complex. When I have a client clearly becoming more disorganized, paranoid, delusional, whatever, it's most likely because they refuse to take their medications. Unless the person is under the care of a hospital or institution, there is little that anyone can do to make him take his pills. A fellow client will tell me her concern for her neighbor. Some will complain about another person's bizarre behavior. Short of an actual threat towards himself or others, I can only do my best to persuade and help him change his decision to forego medication. But here's the rub: the poor guy's cognitive functioning grows worse and worse without his medication. How then can he appreciate his own illness and the effect he has on his community? The law does not state that he understand his right in order to have it. He just has an inherent right to reject treatment.

Here are the most common responses someone gives for failing to take their medicine:
1. I'm not sick.
2. I did take my medicine.
3. They make me feel drowsy.
4. You can't tell me what to do.

So I watch as the auditory hallucinations return. I watch as his personal hygiene declines and he looks more and more like the homeless bum he used to be. I watch as he walks in front of traffic or screams at no one in particular. I have to wait until he is at the tipping point, the moment when he presents enough behaviors for me to call emergency services or a mobile crisis team. I've had to argue with police officers and EMS workers to take someone into custody because they don't see what I do. And even if I get the person into the hospital, some hospitals may just keep him for observation, about 24 to 48 hours, and then discharge him. Why? Because he is no longer an immediate threat to himself or others. So I resume the game of waiting, acting, and hoping.

This is the reality of providing mental health in the community. We do our best but we are only a cog in the machine that tries to keep chaos from overwhelming reality. To be fair, most of our clients do very well and understand the need for treatment. They take responsibility for their actions. But a very ill person, someone who truly cannot negotiate between the demands of our tough world and their own fragile one, can harm someone without realizing the consequences. In my state, there are some provisions for a judge to enforce a doctor's order, but no one can still compel a person to actually accept or receive treatment while he is in the community: refusal of a judge's order only means a trip back to the hospital. And then you have to actually get the police and find him. So a judge's mental health order is no better than a domestic violence victim's Order of Protection (and we know how protective that is!).

I'm a social worker, so I do my best to remind people of their rights, especially when they have to deal with government bureaucracies. As I mentioned before, most of our folks do well. But no one has the best answer to address those not wanting treatment. Would that I had a few minutes to chat with Dr. King, he might be able to offer a little insight. Maybe...