Far from respecting civil liberties, legal obstacles to treating the mentally ill limit or destroy the liberty of the person

By Herschel Hardin
The Vancouver Sun July 22, 1993
Republished with permission

Herschel Hardin is an author and consultant. He was a member of the board of directors of the Civil Liberties Association from 1965 to 1974, and has been involved in the defense of liberty and free speech through his work with Amnesty International. One of his children has schizophrenia.

The public is growing increasingly confused by how we treat the mentally ill. More and more, the mentally ill are showing up in the streets, badly in need of help. Incidents of illness-driven violence are being reported regularly, incidents which common sense tells us could easily be avoided. And this is just the visible tip of the greater tragedy – of many more sufferers deteriorating in the shadows and often, committing suicide.

People asked in perplexed astonishment: ” Why don’t we provide the treatment, when the need is so obvious?” Yet every such cry of anguish is met with the rejoinder that unrequested intervention is an infringement of civil liberties. This stops everything.

Civil Liberties, after all, are a fundamental part of our democratic society. The rhetoric and lobbying results in legislative obstacles to timely and adequate treatment, and the psychiatric community is cowed by the anti-treatment climate produced. Here is the Kafkaesque irony: Far from respecting civil liberties, legal obstacles to treatment limit or destroy the liberty of the person. The best example concerns schizophrenia.

The most chronic and disabling of the major mental illnesses, schizophrenia involves a chemical imbalance in the brain, alleviated in most cases by medication. Symptoms can include confusion; inability to concentrate, to think abstractly, or to plan; thought disorder to the point of raving babble; delusions and hallucinations; and variations such as paranoia. Untreated, the disease is ravaging. Its victims cannot work or care for themselves. They may think they are other people – usually historical or cultural characters such as Jesus Christ or John Lennon – or otherwise lose their sense of identity. They find it hard or impossible to live with others, and they may become hostile and threatening. They can end up living in the most degraded, shocking circumstances, voiding in their own clothes, living in rooms overrun by rodents – or in the streets. They often deteriorate physically, losing weight and suffering corresponding malnutrition, rotting teeth and skin sores. They become particularly vulnerable to injury and abuse.

Tormented by voices, or in the grip of paranoia, they may commit suicide or violence upon others. Becoming suddenly threatening, or bearing a weapon because of delusionally perceived need for self-protection, the innocent schizophrenic may be shot down by police. Depression from the illness, without adequate stability — often as the result of premature release — is also a factor in suicides. Such victims are prisoners of their illness. Their personalities are subsumed by their distorted thoughts. They cannot think for themselves and cannot exercise any meaningful liberty. The remedy is treatment — most essentially, medication. In most cases, this means involuntary treatment because people in the throes of their illness have little or no insight into their own condition. If you think you are Jesus Christ or an avenging angel, you are not likely to agree that you need to go to the hospital.

Anti-treatment advocates insist that involuntary committal should be limited to cases of imminent physical danger — instances where a person is going to do bodily harm to himself or to somebody else. But the establishment of such “dangerousness” usually comes too late — a psychotic break or loss of control, leading to violence, happens suddenly. And all the while, the victim suffers the ravages of the illness itself, the degradation of life, the tragic loss of individual potential.

The anti-treatment advocates say: “If that’s how people want to live (babbling on a street corner, in rags), or if they wish to take their own lives, they should be allowed to exercise their free will. To interfere — with involuntary commital — is to deny them their civil liberties.” Whether or not anti-treatment advocates actually voice such opinions, they seem content to sacrifice a few lives here and there to uphold an abstract doctrine. Their intent, if noble, has a chilly, Stalinist justification — the odd tragedy along the way is warranted to ensure the greater good. The notion that this doctrine is misapplied escapes them. They merely deny the nature of the illness. Health (Official) Elizabeth Cull appears to have fallen into the trap of this juxtaposition. She has talked about balancing the need for treatment and civil liberties, as if they were opposites. It is with such a misconceptualization that anti-treatment lobbyists promote legislation loaded with administative and judicial obstacles to involuntary committal.

The result, …will be a certain number of illness-caused suicides every year, just as surely as if those people were lined up annually in front of a firing squad. Add to that the broader ravages of the illness, and keep in mind the manic depressives who also have a high suicide rate. A doubly ironic downstream effect: the inappropriate use of criminal prosectuion against the mentally ill, and the attendant cruelty of commital to jails and prisons rather than hospitals. Corrections officials once estimated that almost one third of adult offenders and close to half of the young offenders in the correction system have a diagnosable mental disorder.

Clinical evidence has now indicated that allowing schizophrenia to progress to a psychotic break lowers the possible level of future recovery, and subsequent psychotic breaks lower that level further – in other words, the cost of withholding treatment is permanent damage. Meanwhile, bureaucratic road-blocks, such as time consuming judicial hearings, are passed off under the cloak of “due process” – as if the illness were a crime with which one is being charged and hospitalization for treatment is punishment. Such cumbersome restraints ignore the existing adequate safeguards – the requirement for two independent assessments and a review panel to check against over-long stays. How can such degradation and death — so much inhumanity — be justified in the name of civil liberties? It cannot. The opposition to involuntary committal and treatment betrays profound misunderstanding of the principle of civil liberties. Medication can free victims from their illness — free them from the Bastille of their psychosis — and restore their dignity, their free will and the meaningful exercise of their liberties.

The Vancouver Sun July 22, 1993

Reprinted with permission. Copyright 1993 The Vancouver Sun. All rights reserved.

College Mental Health Crisis

STAFF REPORT—

When I look back at college, I can say with utter certainty that “these were among the best days of my life.”

I was “independent” and “free” (both words I enjoyed using) and I considered myself unfettered by parental monitoring.

I forged new relationships.

I stayed out late.

I had meaningful and existentially provocative conversations with classmates.

I fell in love.

What’s not to like?

Ironically, it turns out that these very features of college – the unfettered independence and developmental exploration that I relished – can make college great for some young people, and at the same time can make college absolutely miserable for others.

When I was in college, there wasn’t much room for the miserable part.  Universities acted like the emotional hardships of being away from home were unusual and rare and administrations largely ignored these issues.

Today, things have definitely changed.

Colleges acknowledge that students experience profound emotional struggles, but colleges have remained largely ill-equipped to help these students.

Let’s look at the good, the bad and the ugly of the college mental health universe.

The Good

There are more opportunities for developmental growth than ever before. Colleges actively recognize the immense variety of ways that young people come of age. There are academic and extra-curricular offerings for people to explore who they are and what values they hold dear. This is especially the case for special programs designed to support women and minorities, programs that we never dreamed would occur as recently as 20 years ago.

The Bad

We’re also seeing increasing drop-out rates, more powerful distractions from the online world, and greater academic and social expectations for students.  Add to this the ever-growing financial challenges for students and parents and the decreased certainty of finding a job, and we have the cliché of the “perfect storm” for the emotional stress of higher education.

The Ugly

As we said above, despite great strides, colleges remain largely ill equipped to negotiate these complex psychosocial waters.

As students in the United States head back to college for the winter term, we’d like to address some of the greatest psychological challenges facing universities and their students. This week we’re going to tackle the most disturbing and unsettling issue in college mental health – the possibility of deliberate self-harm and even suicide among university students.

We don’t want to be too alarmist.  Although suicide attempts on college campuses do appear to be increasing, it is not the case that simply being in college means that someone will more likely consider suicide.  However, because many psychiatric illnesses have their natural onset among college-aged individuals, students are at higher risks when these illnesses coincide with the college-related stressors we’ve outlined above.

Consider these statistics:

  • There are more than 1,000 suicides on college campuses each year – That’s 2-3 deaths by suicide every day
  • Suicide is the second leading cause of death among college-age students
  • More than half of college students have had suicidal thoughts, and 1 in 10 students seriously consider attempting suicide
  • Most importantly: 80-90% of college students who die by suicide were not receiving help from college counseling centers

These are of course alarming statistics. Some have even called this a crisis.  The most important question to ask, therefore, is this:

What can we do to improve the situation?

To answer this question, let’s start by looking at what we know about college suicide.

Attempts at suicide and death by suicide are most common in college students who:

  • Are depressed
  • Are either under the influence of substances, or have a substance use problem
  • Have made a previous attempt
  • Have a family history of a mood disorder such as depression or bipolar disorder
  • Are struggling with a history of trauma

We also know that students often tell others when they’re emotionally struggling, and that teachers, peers and resident assistants are more adept at recognizing emotional distress among struggling students.

Nevertheless, suicidal students often feel helpless, hopeless, and trapped. Some of these students resist seeking help because they’re ashamed.  They might fear a “black mark” on their record or being judged by others.  Even if they don’t have these concerns, they often don’t know what services are available.

Obviously, this is a complex and multi-faceted issue.  We won’t be able to rectify this trend overnight.  But there are steps we can take to ameliorate the risks.  These include:

1.  Establish new educational platforms about depression and suicide.  Key to prevention and early intervention is education about mood disorders and suicide risk.  Some educational initiatives include live and online modules that can be used in a wide range of forums on campus – from dorms to the classroom to campus-wide events. These modules are not just for students; parents and faculty benefit as well.  We also need to be more creative in our educational approaches. For example, a film series on depression and suicide followed by discussion groups could be an incredibly powerful way to educate the community.  There are a number of very informative online sites that can serve as adjuncts to these educational efforts.  Chief among these are Griffin Ambitions, the American Foundation for the Prevention of Suicide and the Jed Foundation.  Another important component includes making students aware of what they can and should do if they are worried about a friend or fellow student. In fact, everyone on campus needs to know where to go and what to do when there are safety concerns.  Each college campus should have a user-friendly website or app that features a clear description of the risk factors for suicide and self harm and explicit advice about how to approach a student about whom there are question

2.  Increase access to mental health services.  Every member of the university community as well as parents and family should know how to seek help on and off campus.  A college website can house all the needed information about these services, including information about clinicians and the nature and coverage provided by insurance.  This information should also include clear directions about how to access the best emergency departments either on campus or in local hospitals if serious concerns are warranted

3.  Support community forums.  Most students struggling with a mental illness or emotional crisis feel alone and frightened.  Study after study tells us that we feel better and safer with social supports.  Providing community forums on a regular basis, and throughout the campus, sends a key message: You are not alone, and something can be done about your suffering.

4.  Foster peer counseling.  Depressed and suicidal students are often more likely to talk with friends than parents, teachers or advisors.  We have seen this demonstrated in the success of the programs like AA for substance use disorders and in support groups for all sorts of emotional and behavioral difficulties.  Organizations such Active Minds, tailored to college students, have been highly effective in the mission of peer counseling.

5.  Decrease the stigma of mental illness.  Perhaps the greatest barrier to seeking help is the fear of being judged or ridiculed. Many individuals still do not believe that depression and mood disorders are illnesses and feel that suicide is a sign of deep personal weakness.  Colleges need to take the lead in dispelling these false beliefs. Treatments for depression are effective, and the entire college community needs to be aware of this fact.

6.  Promote means for increasing student wellbeing.  Depression is often prevented by a number of activities – regular exercise, good sleep habits, substance use awareness programs, group discussions, cognitive behavioral techniques, expressive arts, and discussion groups have all proven helpful. These activities should be encouraged and fostered on college campuses.

Because each college is unique, colleges must tailor these initiatives to their own circumstances, but the benefits of taking action cannot be underestimated.  Colleges can literally save lives. They just have to act.

This blog was originally posted on The Clay Center for Young Healthy Minds at Massachusetts General Hospital and includes a podcast reviewing the college mental health crisis.

For additional information please see:

From the Clay Center

When Kids Leave Home: Part 1

When Kids Leave Home: Part 2

Examples of college webpages:

Counseling & Psychological Services – University of Pennsylvania

Mental Health and Well-Being – Cornell University

Dear Teachers & Professors,

An open letter to those in education

Dear teacher(s)  professor(s),

TO WHOM IT MAY CONCERN:

I am a person living with mental illness. Odds are, I’m not the only person in your life who faces this — whether you know it or not. Your knowledge about mental illness may be limited to what the media says, or what society says. With the alarming amount of college students with mental illness these days, I would hope you’ve educated yourself on this topic.

I am a person living with mental illness. I’m also a good student. Yes, I may have missed class, not participated in a discussion or turned something in late, but if that’s all you see then you’re not seeing the whole picture. I’m not asking for excuses or looking for a way to get out of assignments or rules. I would love to be able to adhere to everything without a problem. But I can’t. I have a disability, and even the department that provides accommodations for disabilities doesn’t help much. Aside from the scars on my body and physical symptoms of panic attacks, my illnesses are invisible.

When I don’t come to class, you may see a student who is lazy or didn’t feel like coming. But what you don’t see is the restless night I had tossing and turning with my insomnia. You don’t see the black mass encompassing my entire being some days. You don’t see the fight in my mind between staying alive or giving up. I’m not just lazy. It’s not because I didn’t finish the homework. I wasn’t in class because I couldn’t get out of bed today. I could not face the light of day because my depression had chained me to the darkness of my room.

I had a teacher tell me once it wouldn’t be fair to the people who always made it to class if my absences didn’t affect my grade. At the time, I understood. But looking back now, I realize that makes no sense. Accommodations exist for people with disabilities for a reason. By “understanding” but still penalizing me for something caused by my mental illness, you are keeping me at a disadvantage. It’s not fair to expect I be on par with other students who don’t have the added obstacle of an illness. I promise I’m giving it my all. I’m balancing my recovery and my education at the same time, and I shouldn’t feel like I have to choose. I shouldn’t feel like I can’t do both.

I’m not asking you to never expect me in class or constantly give me extensions. I’m not saying to just let it slide. I’m asking you to be empathetic, understand that I’m a student facing an illness and help me succeed. I’m asking you to not give me a low grade solely because my mental illness prevented me from having a perfect attendance. I’m asking that you look at me as a whole person. I’m asking that you care, and if you can, that you advocate for students like me. I’m a person living with mental illness, and there are so many of us who need your understanding.

-JACOB M. GRIFFIN
BALL STATE UNIVERSITY
FOUNDER OF GRIFFIN AMBITIONS LIMITED, A HOOSIER BASED 501c/3 NON-PROFIT
FOUNDER OF ACTIVE MINDS AT BALL STATE UNIVERSITY