Friday, January 04, 2008

Mentally Ill Offender Treatment and Crime Reduction Reauthorization and Improvement Act of 2007

When Congress readjourns after the holidays, those of you interested in following legislation may want to watch for Senate Bill 2304 (H.R. 3992), the Mentally Ill Offender Treatment and Crime Reduction Reauthorization and Improvement Act of 2007.

This is a bill which provides for the training of law enforcement and campus security, to help them identify and respond to incidents involving mentally ill people and for the development of receiving centers for the assessment of people in custody. It extends funding for the development of mental health courts. It also authorizes a survey of people on parole or probation, or in jail or prison, in order to determine how many suffer from serious mental illness and may be eligible for SSI, SSDI or medical assistance.

The House version of the bill made reference to providing grants to help correctional facilities screen for mental illness and treat mentally ill offenders while they were incarcerated, but I didn't see any language specific for this in the text of the bill. Hopefully this will actually be included. Usually when it comes to appropriating money for forensic patients, the money goes to free society interventions and completely ignores the fact that they still have treatment needs when they're locked up. I'd really like to see some serious funding set aside to look at the best care delivery methods in institutions and ways to transition that care back into the community. Right now the only way anyone pays attention to this is when a correctional system is sued for deficiencies; then loads of taxpayer money gets spend figuring out what needs to be fixed. I think a proactive approach might be a bit more cost effective.

Then again, maybe I'm just guilty of attempted common sense. It wouldn't be the first time.


Dragonfly said...

I agree

Zoe Brain said...

Can I sound off about my standard obsession now please?

How do you define Mental Illness? I mean, from a legal standpoint, rather than one based on Reality?

Does it include everything in the DSM-IV? Does it exclude everything else?

Real World Example re Prisons:
One view. Another view. Yet another view:

A leading US psychiatrist who conducted an in-depth investigation into the results of sex-change therapy concluded that the psychiatric community was cooperating with mental illness by diagnosing transsexualism as a legitimate physical condition. “We psychiatrists… would do better to concentrate on trying to fix their minds and not their genitalia,” Dr. Paul McHugh, University Distinguished Service Professor of Psychiatry at Johns Hopkins University wrote in First Things, 2004.

First Things is not a medical journal, but a religious one.

Nonetheless, Dr McHugh's views have been used as the basis for an IRS ruling that any medical treatment for transsexualism is not tax-deductible, and has been quoted in virtually every legal case dealing with the subject - including the one in the other references.

The "in-depth investigation" was
conducted over 30 years ago, and has been contradicted by every single investigation available in PubMed ever since then, but he is Henry Phipps Professor of Psychiatry and Director of the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine, and Psychiatrist-in-Chief of the Johns Hopkins Hospital. His views are most cogently expressed in Psychiatric Misadventures.

The zeal for this sex-change surgery--perhaps, with the
exception of frontal lobotomy, the most radical therapy ever
encouraged by twentieth century psychiatrists--did not derive from
critical reasoning or thoughtful assessments. These were so faulty
that no one holds them up anymore as standards for launching any
therapeutic exercise, let alone one so irretrievable as a
sex-change operation. The energy came from the fashions of the
seventies that invaded the clinic--if you can do it and he wants
it, why not do it? It was all tied up with the spirit of doing your
thing, following your bliss, an aesthetic that sees diversity as
everything and can accept any idea, including that of permanent sex change, as interesting and that views resistance to such ideas as uptight if not oppressive. Moral matters should have some salience
We need to know how to prevent such sadness, indeed horror.
We have to learn how to manage this condition as a mental disorder
when we fail to prevent it. If it depends on child rearing, then
let's hear about its inner dynamics so that parents can be taught to guide their children properly. If it is an aspect of confusion tied to homosexuality, we need to understand its nature and exactly how to manage it as a manifestation of serious mental disorder among homosexual individuals. But instead of attempting to learn enough to accomplish these worthy goals, psychiatrists collaborated
in a exercise of folly with distressed people during a time when "do your own thing" had something akin to the force of a command.

When these words were written, it was possible to defend them. There's a lot in there that I agree with - I'm rather conservative myself. But the (necessarily low sample size thus not definitive) autopsy and MRI results and so on that appear to show biological causation have been matched with a very, very low rate of cure from psychiatric techniques - comparable to that of curing cancer by prayer. Despite searches over 40 years, there's no pattern, no evidence that it's tied to either child-rearing or homosexuality, or anything else in environment in the general case. So much of what was in psych textbooks of even as late as 20 years ago has been debunked, yet myths not supported by evidence persists.

I was amazed and dismayed when giving a 10-min "tail end" briefing to some med students after a Psych Prof's end-of-course lecture on abnormal sexual development to have to correct so much misiniformation. FtoM transitions are not "so rare as to be almost unknown", though whether the incidence is 25% or 50% of the total figure is unclear now (it's 55% in Poland - who ordered that?). Our future psychs are being taught such guff, it's disheartening.

In this context, who decides whether this deeply distressing condition (and others) is a mental illness from a legal standpoint, and if so, what treatment(s) are appropriate?

I might nail my colours to the mast here. We're still not certain what caused what some would call my "involuntary sex change", welcome though it was, and partial though it had to be in purely biological terms. There's been no psych studies I can find of the far more common partial/apparent "involuntary sex changes" of males with 5 alpha reductase deficiency, or 17BHDD. Some passing remarks about how it makes no difference to some, yet to a minority is a medical emergency, but that's it.

Anyway, I feel that this gives me if not a unique, then an unusual view.

I see transsexuality as a physical intersex condition, but one that causes Gender Dysphoria, a form of chronic misery, and often Gender Identity Disorder, a full-blown psychiatric condition that is terribly debilitating. Remove the root cause, and those conditions disappear, though co-morbidities caused by a lifetime of sheer misery will remain.

I might be wrong, but this fits the facts. I've yet to see evidence that the Gender Dysphoria can be removed without treating the root cause too, it's certainly usually intractable.

This rambling essay was just to explain by real-world example the vexed question of what is a legal "mental illness" and what is "appropriate therapy" in the context of the law in question. It also has personal interest of course. For one thing, I've just won a 20-month fight involving legal letters, court cases etc to be granted an Australian passport. It normally takes 3 weeks. The fact that I had to go through legal difficulties like that, that it seems normal, expected even for people such as myself, seems, well, Crazy. Call it a "persecution simple".

I have dual citizenship, UK/Australian. In Australia, should I get divorced, I could only marry a man - in order to prevent "same-sex marriage". In the UK, I could only marry a woman, also to prevent "same sex marriage". This is causing some degree of hilarity, but also genuine disorientation. I could do with reassurance that this kind of legal stuff is insane, rather than just me.

ClinkShrink said...

Zoe: You asked a great, important question:

"What is a legal "mental illness" and what is "appropriate therapy" in the context of the law in question?"

When it comes to the law, a mental illness is whatever the factfinder decides is a mental illness. The factfinder is the judge or jury hearing the case. They may consider the testimony of expert witnesses (eg. psychiatrists or psychologists or surgeons who do sex change procedures) but the ultimate decision is up to the court. In the U.S., a mental illness does not have to be defined in the DSM to be considered an illness in the legal sense. Factfinders are free to accept or reject expert opinion---and at times they do reject it.

The issue of appropriate therapy is also an interesting one, because in the course of medicolegal decisions, the judiciary has sometimes intervened to set new medical standards of care. For example, before the 1960's there was no standard of care for providing informed consent for treatment. This was established by litigation and subsequent case law. Similarly, the mental health professionals' duty to warn of dangerous patients was a standard of care imposed by the courts. Courts have the option of deciding the sex change operations are in deed appropriate therapy and standard of care for the treatment of gender identity disorder and gender dysphoria. Whether or not this will become national standard in the U.S. remains to be seen, as your links suggest. (Thanks for the information.)


"I could do with reassurance that this kind of legal stuff is insane, rather than just me."

It's not just you. Sometimes laws really can seem insane.

Roy said...

It is all rather messed up, Zoe. Also, to extend Clink's remarks about what is a "mental illness" from a legal standpoint, it can also be something that is statutorily defined in law.

For example, in Maryland, for the purposes of scope of practice (who can diagnose what), a "mental illness" is defined as any illness listed in the DSM (most people would not call "primary insomnia" a mental illness).

So these definitions can be particular to a narrow range of law, so the fine print is important.

Zoe Brain said...

Thanks for the re-assurance.

Although these matters are important to me, I can't help thinking about Clinkshrink, constantly dealing with severely dysfunctional people who need extensive treatment, and doing so on a proverbial shoestring.

Handing out meds in crises, with every assurance that the patients will leave the clink no better, sometimes worse, and with none of the follow-up essential professional help they need.

In that context...and putting things into perspective... thanks even more for taking the time to address what is in comparison, a minor matter.

On the topic of follow-ups: I just saw my own shrink - first time in a year - just to let her know how things are going. Usually TS people get the op, and disappear off the face of the planet. They "woodwork", and none of their professional treatment team knows whether the treatment was successful or not. They assume it is, but really can't know, lacking data.

I intend seeing her once a year for the next five years just to give her one data point. I encourage others to do the same. All the readings on the subject I've seen show a dearth of follow-up data, and we should do what we can to address this.

My own ideas might be right, or I might be completely off-base. But without the data, how can we know either way?

There's another aspect too. Medics like to know when they've done well, when the patient has made a complete recovery. It makes them feel good. They should get more of it. It's the best kind of thanks patients can give them. Shrinks are people too, No?