The Definition of Insanity

I want to interrupt my posts about neurotransmitters and basic neurobiology.  This is something I thought may be interesting to my readers.

For those of you who are not familiar with the current mental health system, I would like to explain a little about the current system in Oregon.

When someone has a major mental illness like schizophrenia or severe bipolar disorder there is very little help for them. Most people with severe psychosis have anosognosia. Anosognosia is the inability to correctly accept the reality of having a mental illness. In simple terms, they are “experiencing ‘lack of insight’ or ‘lack of awareness.'” (NAMI) It is not the same thing as being in denial. It refers to the person being able to aware of their mental illness.

These severe mental illnesses contribute to behaviors that they would most likely avoid if they had the mental capacity to do so. Most people who have severe mental illness such as schizophrenia do not commit violent crimes. In fact, most violent crimes are committed by people without mental illness.  In the United States, “the incidence of violence was higher for people with severe mental illness, but only significantly so for those with co-occurring substance abuse and/or dependence,” (Elbogen & Johnson, 2008). That said, people with severe mental illness are much more likely to become victims of the violence rather than the perpetrators. Substance abuse in the severely mentally ill, increase the likelihood that they will commit a violent crime. The good news is that those who are successfully treated for their illness are no more violent than the general population.

Most people with severe mental illness that are arrested, face misdemeanor charges. These are non violent crimes. Examples might include trespassing, resisting arrest, or theft. Maybe they’re homeless and they were sleeping on a park bench and were arrested, but because of their illness they were afraid due to paranoid delusions. When a law enforcement officer attempts to interact, the voices in their head may tell them that the police officer is going to try to kill them. Due to this fear, they fight to get away which is resisting arrest.

After they are arrested and placed in jail, they are not able to assist their court appointed attorney in their own defense. They sit in jail for months. They aren’t required to take any medications in jail and because of anosognosia, which we talked about earlier, they don’t believe they need any. Their attorney may file paperwork a few months later to the court, stating the person with the mental illness is not competent to go to trial. The judge signs the order and the mentally ill person is eventually sent to the State Mental Hospital.

This is where I come in. I work at the State Hospital as a psychiatric mental health nurse practitioner (PMHNP). When the patient arrives, I assess the severity of their mental illness, diagnose them, and order treatment. If the patient declines medication and is not eminently considered a danger to themselves or others, then I cannot legally prescribe psychiatric medications against their will; however, our job is also to prepare them for a psychological evaluation to assess their ability to aid and assist their own defense. Many times, after a while, their behavior becomes dangerous and they are given medications involuntarily.

About 60 days after they arrive to the hospital, they meet with a psychologist who assesses their knowledge of the legal system and their case. The psychologist decides whether or not the patient is able to do this. If they are found “able,” they go back to the jail and then to court to face their charges. If they are found “not able,” they stay at the hospital until they pass the evaluation or the “end of jurisdiction” if they cannot eventually pass the evaluation. The “end of jurisdiction” is the time the judge appoints for them to leave the hospital. Generally it is 3 years.

This system is very poor as we have many, many patients leave the hospital and despite the hard work of the social workers, nurses, nurse practitioners, mental health technicians and care planners, the patients go back to living on the street. They stop taking any medications, commit more crimes, go back to jail and the cycle begins again.

This cycle costs MILLIONS of taxpayer dollars which are not necessary. Our jails have become a housing place for the mentally ill. We have criminalized mental illness. If you have high blood pressure and while you’re driving you have a heart attack and pass out and hit a pedestrian, you would not be arrested and taken to jail. No! You would receive treatment for your heart problem. Why do we think of severe mental illness as something that makes an I’ll person a bad person who should be put away?

This documentary gives a solution regarding this merry-go-round of jail, mental hospitals, and the court system. It’s approximately one hour but completely worth your time. Leave a comment and let me know what you think!

The Definition of Insanity

References:

Elbogen EB, Johnson SC. The intricate link between violence and mental disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2009 Feb;66(2):152-61. doi: 10.1001/archgenpsychiatry.2008.537. PMID: 19188537.

NAMI. https://www.nami.org/About-Mental-Illness/Common-with-Mental-Illness/Anosognosia