One of the more troubling issues I have encountered in my 15 years of the practice of psychiatry is the frequency with which agencies work to evade responsibility and accountability for the clients they are supposed to serve. No agency is immune to this problem, but in my experience, one of the most egregious situations goes something like this:
Joe is a 33 year old man seen on the grounds of a local elementary school. He is not recognized by school staff, and the police are called. Upon approach by police officers, he appears not to understand their direction to leave the grounds.
Instead, he approaches the playground area where the kindergarten class is currently playing. The police officers take hold of his arms, at which point Joe begins screaming and fighting to extricate himself from their hold. He is charged with trespassing on school grounds, resisting arrest, and two counts of assault on a law enforcement officer.
Upon entry into central booking, Joe does not answer any questions, instead sitting rocking on the bench. Other arrestees tell detention staff “there’s somethin’ wrong with that dude – he’s crazy!” Joe is referred for an urgent mental health assessment, where he stares over the evaluator’s head as if seeing someone behind the clinician. He is placed in the mental health area of the booking center and a psychiatrist is called. The psychiatrist diagnoses Joe with schizophrenia and orders antipsychotic medication, which Joe refuses. When taken for his bail review three days after his arrest, the court orders a competency assessment, and Joe is placed on the list for a forensic psychiatric evaluation.
When seen for the evaluation at the court clinic, Joe is still generally silent, but at times he echoes the last words of the questions posed to him. He is found by the forensic evaluator to be incompetent to stand trial, and he is committed to the hospital for treatment and restoration to competency. During his stay at the hospital, staff eventually are able to engage Joe sufficiently to track down Joe’s mother, who reports that “Joe was always a bit off. He was in special education classes at the school where he got arrested.” When records from the school system are sought, the hospital staff are told “FERPA requires us to destroy special education records after 5 years.”
What is Joe’s real diagnosis? It appears that instead of schizophrenia, Joe has a developmental disorder such as autism or a similar pervasive developmental disorder. These types of disorders require very different treatment and rehabilitation approaches from the more familiar mental illnesses like schizophrenia or bipolar disorder. Typically, mental illnesses respond to medications, while the developmental disorders require a more comprehensive behavioral approach.
More problematic is the system of care. In many – perhaps most – states, one agency is responsible for the care of people with mental illness, and another is responsible for people with developmental disabilities such as autism or intellectual disabilities (formerly known as “mental retardation”). Whereas people with mental illness can be hospitalized urgently if they meet civil commitment criteria (problem enough, as discussed in my June blog entry), those with developmental disabilities must prove that they are sufficiently impaired and that the impairment began in childhood before benefits are provided. As the vignette illustrates, the childhood origin can be difficult to prove even when it is known where the individual attended school; it is often impossible to get even this information, if the person is unable to communicate or if he is from another country. Thus, individuals who really require a behavioral approach to remedy or address their deficits end up in a psychiatric system that cannot say no, that is ill-equipped to manage them, and they are often inappropriately treated with medications that cannot be effective and that only lead to adverse effects over time.
I have consulted on cases and systems in many states, and I always hear the same thing: “How can we get these agencies to coordinate better?”
Erik Roskes is a forensic psychiatrist and currently the Director of Forensic Services at the Springfield Hospital Center in Maryland. The opinions expressed are those of the author only, and do not represent those of any of Dr. Roskes’ employers or consultees, including the Maryland Department of Health and Mental Hygiene. He can be found at http://mysite.verizon.net/eroskes/
Read full entry »Read more of Mark's work at his blog D.A. Confidential.
There has been much talk of closing prisons here in Texas. The Crime Report covered that issue a week or so ago, and the local paper has also written about it. From what I've read, the move seems budgetary rather than a result of some philosophical shift, and as I sit down to contemplate the subject a case that came up in court this week seems like a good representation of how I feel.
Several years ago, a couple of guys arrived at a business here in Austin and robbed it at gunpoint, tying up the proprietor, who was terrified beyond belief. A woman drove the getaway car, but did not go in. They were caught and the gunmen got prison, she got probation. This week, she was before the court because, not for the first time, she’d violated the terms of her probation by using an illegal substance. Each time, she’d been continued on probation rather than having it revoked and being sent to prison. Mostly because the violations weren’t that bad, the minimum prison term for her is five years, she has several children, and is pregnant with another. Today, she wept and told the court that she’d smoked weed, yes, but done it because when she smoked the beatings she got from the man she lived with hurt less. A made-up story for sympathy? Sounds like it, except she went to SafePlace (a shelter for abused women) and told them the same thing before being picked up for the probation violation. As frustrated as we might have been with the violation, she bought some sympathy and credibility by her admission, and by her admission that she wanted treatment for her drug use
So it became a stark choice: either she gets prison for a bad act followed by repeated failures to abide by probation conditions, or she is left on probation in the hope that the reasons (or excuses, depending on your perspective) stop. I think it’s fair to say that most of us (except the defense lawyer, I guess) were tired of excuses, aware of the serious underlying offense, and starting to wonder if it was impossible to make someone take hold of their life and turn it around. But we all agreed, ultimately, that this time prison wasn’t the answer so she was sent to in-patient treatment for her repeated drug use, somewhere she’d be safe from abuse, where she could work on the many issues she obviously has. Make no mistake, she’s on thin ice and knows it, I’m guessing she won’t get any more breaks if she doesn’t get her act together. After all, there’s only so much the state can do when it comes to offering a helping hand. But I think it was the right thing to do, for her, for her children, and also when you look at the cost of imprisoning someone like her. Would prison make her a better member of society when she gets out? Unlikely. Is she a danger to those around her? Certainly not, if she takes to the treatment.
I also think that her case is emblematic of how the criminal justice system has been going lately, certainly in my county. Just the other day I ran into a reporter who was gathering information for a story about all the programs running in the county that work to “fix” people, rather than imprison them. Drug courts, DWI courts, all those.
Make no mistake, there are times when people have been offered help, assistance, support, and treatment. Times when we offer mercy and what we see as justice, but they see as weakness. Some people won’t help themselves, they just don’t want to put in the time and the effort.
They don’t seem to realize that life is hard for all of us, we all have to work and make sacrifices. They have, and I’ve seen it, a sense of entitlement and for them leniency is just a way of amassing convictions without prison time. I have no problem with the criminal justice system keeping a hammer in its back pocket for those cases. But in general, as happened this week, I am inclined to think that a few helping hands will fix more problems than prison, and cost us less to boot. A long- and short-term savings, coupled with the salvation, if you will, of individuals has got to be a good thing, right? With prisons closing, perhaps we can make the rehab thing work. One just hopes that those in charge of the purse-strings don’t look for a cut in those other programs, too, because I’m certainly not in favor of opening up the prison doors just to save money, with nothing else to keep our streets safe. But here’s a quote from the Austin American Statesman’s story:
“Closing prisons? It's absolutely on the table,” said House Corrections Committee Chairman Jim McReynolds, D-Lufkin, whose panel oversees the state-run system of lockups. “As tight as our budget situation looks, we cannot unravel the fledgling system of diversion and treatment programs that are paying big dividends now for the states. And there’s only one other place to look — prison operations.”
So maybe a budget crunch is just what we needed. I know at 160-odd cases that I’m handling, a wee drop in customers would be more than welcome.
Read full entry »Barack Obama campaigned for president on a platform of change, but how will that apply to drug policy? Not much specific is known now. Clues are likely to emerge in the next few weeks as important administration figures visit Mexico and Obama drug czar nominee Gil Kerlikowske, Seattle police chief, appears at his Senate confirmation hearing.
It is assumed that the president will take a softer line on drug enforcement than did the Bush administration but what that means in practice is yet to be seen. Attorney General Eric Holder gave a hint when he said that federal drug agents no longer would raid medical marijuana dispensaries that were operating in accord with state laws.
Another issue where change seems likely is the more than two-decade-old disparity in sentencing guidelines involving crack and power cocaine. Obama has opposed the 1-100 disparity in power-crack cocaine quantities that trigger a mandatory minimum prison sentence, but it is not clear how that issue will play out in terms of what the new ratio might be, if not 1-1.
On Mexico issues, the administration has signaled that it will do more on the enforcement side, but can that be very effective against powerful cartels and will it do anything about the large demand for illegal drugs in the U.S. that is fueling the border violence?
Eric Sterling of the Criminal Justice Policy Foundation, which contends that the war on drugs has “led to a more efficient drug trade and a hugely profitable drug market,” hopes that the administration will rethink the enforcement-dominated federal drug policy. Sterling would like to see the feds delegate more enforcement to state and local prosecutors, for example. In the meantime, even a “different rhetorical approach” that might be taken by Kerlikowske, “would be dramatic,” Sterling believes.
It's a fair bet that the Obama administration will move to increase treatment and limit enforcement, but how soon anything significant will happen is not known. Drug policy is at best a fourth tier issue behind the economy, health care, and foreign wars, and key personnel moves are far from being made
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