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Mental health in the US: New ideas on care emerge

Mass shootings by mentally unstable people have focused attention on the inadequacies of the US mental health care system, in which less than half of the seriously ill can get treatment. 

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Saying the mentally ill are dangerous discounts the myriad other attributes of their individual personalities, says Jeffrey Swanson, a psychiatry professor at Duke University in Raleigh, N.C. "Mental illness is one thing people might have, but they're also varied in all the other ways that make people inclined to commit violent acts.… [In treatment], you have to think about the whole person and the whole environment, rather than just think about what to do to fix what's wrong with the paralimbic system."

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One of the most prominent voices on the other side of this debate is E. Fuller Torrey, founder of the Treatment Advocacy Center and author of "The Insanity Defense: How America's Failure to Treat the Seriously Mentally Ill Endangers Its Citizens."

Dr. Torrey, who has compiled a database going back to 1987 of what he says are "preventable tragedies" incurred by people with a mental illness (nearly 4,000 just in the past 10 years), believes the pendulum has swung too far in the direction of civil liberties, leaving many people aware of a family member who is deteriorating quickly, doesn't have the insight into his own disease to voluntarily seek treatment, and who may be a danger to himself or others, with no recourse to get help.

"You've got to clean up the commitment laws so that you can evaluate people [without their consent] before they commit a horrendous act," says Torrey. "And you need enough beds to put them in.… No one needs to go back to where we were [before mental institutions were shut down], but we're way below the minimum number."

Sacher, for one, believes that involuntary commitment is sometimes necessary. She credits New York's Kendra's Law – named for a woman pushed to her death in a subway station in 1999 by a man diagnosed with schizophrenia and off his medication – with ultimately helping her daughter gain insight into her illness and get on a track toward recovery.

Lisa was hospitalized six or seven times over the years, mostly after an overdose or if she was in a catatonic state. Finally, in 2002, Sacher got Lisa a court order for assisted outpatient treatment (AOT) under Kendra's Law, lying a bit about the dates of her last overdose to get it.

Mandated outpatient treatment (as opposed to hospitalization) is also controversial and, in some states, means very little: A person is under court order to get treatment, but with little to no enforcement.

"As a crisis-driven knee-jerk reaction, when a state says 'let's pass outpatient commitment laws' – if they don't put a good program in place, it won't do anything," says Dr. Swanson. In New York, though, Swanson and others agree it's been implemented relatively well, with expanded ACT teams in place to help people placed in treatment.

"If you understand better the goals and preferences of the person you're treating you can do a lot better job in treating them," says Burnim of Bazelon, who would like to see more ACT teams in place but without the Kendra's Law mandate. (In New York, ACT teams serve both voluntary and AOT patients.)

That's the approach that finally worked for Lisa, says Sacher.

Outpatient focus that works

More than 17 years after she first became ill, in 2002, Lisa finally stayed with treatment long enough to begin to get insight into her disease. A big part of what helped was being in day treatment with others struggling with the same issues, and having a therapist help her focus on her dreams apart from her illness.

"It was helpful for her to be in a place where the focus of her counselor and therapist was to say, 'What do you want? Let's make a plan. What's your dream?' " says Sacher. "Not, 'What do your parents or doctors want? Let's get you there.' She always felt she was moving forward."


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