I agree with you. Since we no longer institutionalize the severely mentally ill, medicating them is the standard treatment--and, understandably, this is intolerable to some due to the side effects. We just don't have an ideal solution, sadly.
There are programs to integrate severely disabled people enabling them live functional lives, but they are expensive. Institutionalization is cheaper and more appropriate for the severely mentally ill, but deprives them of their human rights. I think it really is a catch-22.
Thank you for posting this as it raises some good points. I hear ya. I know several people that would fit with what you are saying, but there are several important things you are missing. Living with psychosis and refusing to take medication because you don't like the side effects is one thing, living on the streets in not so safe parts of town and eating out of garbage cans while acutely psychotic is another (in my mind). Is this a crisis that requires hospitalization? It would certainly vary from person to person. Regardless of where you fall on the argument no one is really asking the question which is what bothers me. Also, we don't have a very accurate way of determining if these individuals are safe and where exactly their lifestyle will lead them, and there are very few preventative measures (at least in my area) to intervene with them, only reactionary measures (police intervention after a person attacks someone or bothers someone, etc.). And the reactionary measures aren't very effective (and often involve the legal system).
To your first point, how do you determine that they are able to accurately judge their quality of life? There is no mechanism in place to determine that. Do they understand the full implications of their illness and how it may not only influence them but others around them? With schizoaffective disorder, bipolar disorder, etc. just because they are doing okay now, what happens when their mania progresses? Are they aware of the different medication options that are available (even if they have had a bad experience with one of them) and the community resources available to them? We don't really know for many of these people, and no one seems to care to ask. I am not implying we need to institutionalize them, but we need to seriously ask the question. By not intervening we may be indirectly institutionalizing them to homeless shelters or temporary stints of incarceration (as the articles above point out). These things will create a vicious cycle that gives them less of an option of choosing to get treatment, get disability from the government, and living a semi-normal life.
We as a society, and many of us in our profession, have completely ignored the wellness model and the social model of disability with regards to this population.
I appreciate your responding in depth.
🙂
To add to your first point, severe mental illness is often the result of both nature and nurture, and I believe that these people are very susceptible to abuse, especially since they are not considered "respectable". Few people will defend the resident homeless lady who is regularly being visited by various men and we really don't have a long-term way to follow up after they are released to the street. The fact is, their lifestyle is not safe.
On the other hand, you can't just drive around town picking up anyone who looks strange, give them a psych eval, involuntarily commit them if necessary. The result will be major human rights violations at great cost to the hospital. And you must have a follow up program, or you'll be checking in the same people over and over again.
You are correct that we can't measure quality of life, since it is an individual perception. I may require internet access to have a good quality of life, but another person may be happy gathering mangoes in the Amazon as a day laborer. Who are we to determine someone else's quality of life? Maybe some people are meant to test us, to see if we can treat people who refuse to be normal with the same respect we treat humans we think we understand.
From their perspective, the discomfort caused by the medications may outweigh its normalizing effect on their brain. A schizophrenic who understands "the full implications of their illness and how it may not only influence them but others around them" may be depressed knowing that they will always need other's help, can look forward to decreased cognitive ability after each episode, and are unlikely to achieve their original ambitions, in addition to any side effects. I think that for some people, living in their own world, even though it means being on the streets may be less distressing.
In my opinion, forcing medication, so that a person can experience normality, borders on a human rights violation. If a person WANTS to be normal, then we should help them. But we can't help everyone, we need to figure out what is best for each person. Maybe some people need to be institutionalized, and we could start such institutions just as for the developmentally disabled. But running them would be very difficult - we have enough abuses in geriatric nursing homes.
I agree with you that we need to ask the question, but I disagree that floridly psychotic people on the street are necessarily a bad thing. You say that regular use of homeless shelters is a form of "indirectly institutionalizing" but it would seem to me that homeless shelters are very positive. As long as they are protected, have a place to go if they are hungry or need shelter, and treatment is offered to them, we can expect a certain percentage will choose to remain on the street who are harmless and simply add human color.
