Monday, March 26, 2012

Review of Crazy

No no, we're not reviewing what it means to be "crazy."  

I recently finished reading Pete Earley's book,  Crazy: A Father's Search Through America's Mental Health Madness.  Fives stars, two thumbs up, all the way.  It was a quick and engrossing read, I think I got through the whole book in three sittings. 

Mr. Earley starts with the story of his son, a young man just finishing college, who becomes delusional and disorganized.  Efforts to clarify a diagnosis and get him treatment are a bit difficult, in part because he doesn't really want help, and perhaps because these efforts span two states as the son is in school in New York but the father lives in Virginia.  Earley goes to NY to fetch his son, and alarmed that he is so delusional, disorganized, and talking about death, he takes him to an Emergency Room in Fairfax, Virginia where he is told that the son can't be committed against his will unless he has already had a suicide attempt.  The son goes home, does some strange things, then breaks into a random house where he shatters pictures, leaves water faucets running, and takes a bubble bath.  He's no longer in the voluntary psychiatric system, per se, but is now charged with felonies that will prevent him from ever being licensed in his chosen profession.  A plea bargain is reached-- for misdemeanors/probation/treatment--  but in court, the prosecutor can't cut the deal because the homeowner-victim won't allow the crime to be pled out without a felony charge.  Does the victim really get to call the shots on what a criminal is charged with?  

Earley is understandably frustrated with the system and all the roadblocks in everyone's way.  He's worried about his son's future, and a bit terrified that his son will get sick again.  Mike can't catch a break, and his diagnosis and criminal record seem to call his life to a halt for a while.  The son does well on Abilify and Earley could be their spokesman.

 The author decides to explore the system by spending a year following patients in the Dade County (Miami) jails and talks about a psychiatrist he shadows who sees his patients for an average of 12.7 seconds.  Earley describes a whole jail unit full of really sick people who are combative, catatonic, and treatment-resistant, in a way I've never seen in nearly two decades of work in community mental health clinics.  Never....well.... Clink says this is all in a day's work for her, but it's not routine stuff for outpatient psychiatry.   The psychiatric unit he describes in the jail is disgraceful, with cold, naked prisoners lying on the floor next to the toilet, in need of blankets and kindness.  It felt like a human zoo, only in animal zoos, the creatures are treated better, I hope.   The tales Earley tells are sad ones, the people he follows end up still sick, imprisoned, or dead, and the system he describes simply doesn't work.  And the patients, some of them are so sick that there is simply no place on earth for them, and Earley faults the state mental hospitals for releasing them.  Even a well-monitored forensic patient ends up doing well, getting a job and living with his girlfriend, only to kill her.   It's all just horrible.  Real life outpatient psychiatry isn't so bleak, and while there are some awful and sad stories, there are many people who do fine.  I felt badly for Mr. Earley because he chose the most dismal of places to search for answers, and I think (or at least I hope) it's unlikely his son will end up in such devastation.  Along the way, he talks with other parents and becomes involved with NAMI.

The author does a good job of getting inside the mental health system.  I didn't agree with him on his easy separation of substance abuse and mental illness, and I don't think we know that drugs don't cause mental illness; they certainly exacerbate it, induce symptoms that mimic it, and make diagnosis and treatment nearly impossible in some settings. 

Mr. Earley is a proponent of involuntary treatment.  He talks to people while they are living on the street, eating from trash bins, victimized by rapists and robbers, and he doesn't buy that people should have the right to live this way.  Earley twice quotes Wisconsin psychiatrist Darold Treffert as saying they get to "die with their rights on."   He wants state hospitals back and he wants them to treat patients humanely.  

If you oppose involuntary treatment under any circumstances, read this book: it will either change your mind or raise your blood pressure.  

Oh, and if you'd like, try Mr. Earley's website and blog at


EastCoaster said...

I have very mixed feelings about involuntary treatment.

My Mom has a psychotic illness, and there were many times that I wished we could force her into treatment.

I have two big concerns. The first is less tangible. I wonder what this does to the therapeutic relationship.

The second relates to involuntary outpatient treatment. In MA there is a push to set this up under the name Outpatient commitment (attached to a 3 strikes and you're out bill) which they are terming "Assisted Outpatient Treatment." This would put a mandate on community psychiatry providers to ensure compliance without additional resources and would most likely prevent us from serving people who want our help. In MA, we already have something called a Rogers guardian for people who have been adjudicated to be incompetent, who are not considered capable of making their own decisions about antipsychotics which is reviewed quite cursorily by a monitor (usually a lawyer). However, it is true that an individual who is outpatient can refuse to take the medication, and nobody will stuff it down his or her throat unless they get sick enough to need inpatient care.

Liz said...
This comment has been removed by the author.
Liz said...

i started reading that book in the psych ward this summer, but the patient i was borrowing it from got discharged so i wasn't able to finish it. i'd like to finish it, though.

i'll attempt to read it with an open mind, but i imagine you're correct in saying it will raise my blood pressure.

if anyone ever got a court order to force me to take psychiatric medication, i'd launch a hunger strike.

for now, i'll just work like hell to not put my family in a position in which they're forced to choose between locking my ass up or being constantly terrified i'd kill myself.

the other day, i started reading one of earley's newer books, the serial killer whisperer, while visiting barnes and noble. that's one i really, really want to read.

Anonymous said...

Have not read it. Not planning on it. It is disturbing that the author appears to suggest (from my reading of your review) that state hospitals are the answer to homelessness. It is true that the closure of such places resulted in homelessness and people being forced to eat from the trash. Surely we can find a way of providing food and shelter and medical care to people without warehousing them.

George Dawson, MD, DFAPA said...

Adequate psychiatric care with appropriate involuntary treatment is a solution to this problem. It is absolutely appalling to have managed care companies shut down acute care capacity and determine that the length of stay should be worthless for scientific and humane treatment. The only think more appalling is counties and municipalities using jails for 19th century psychiatric hospitals. Commitment courts are also part of this. The only way a person is not held if they have not attempted suicide first is if a court system or county bureaucracy gets that word out. There is not commitment statute in the US worded that way. That is how LA County jail ends up being the largest psychiatric hospital in the US.

Anonymous said...

the only thing I can think about this is, "the system needs to change, for the better" but then that's not news to many.

Not really very helpful, I'm afraid.

I don't have any experience with involuntary commitment except for avoiding it as best I can.

That may change, soon. That or I'll be dead, and honestly the latter sounds more appealing.

But. I'm here, for now. They say if you're going thru hell, keep going. So I'm endeavoring to keep going; the price has been very high for violating my core values.

I should prolly shut up now.

Anonymous said...

I seem to recall a post on Facebook alerts about suicidal people. So this caught my eye:

Anonymous said...

My apologies if this goes through twice, the first time it timed out (I'm on kind of slow connection right now).

Anyway, I read the book and while it didn't change my views on involuntary treatment, it did make me sad. I don't think, though, that the answer is involuntary treatment. I grew up with a family member with paranoid schizophrenia. She has never been homeless, because she has a home. Family paid for her apartment and food. Sometimes she took medications, sometimes not. It seems to me that it would be a lot cheaper to pay for an apartment than house people in state hospitals, not to mention more humane. What is the cost per day to house someone in a state hospital?

We're supposed to treat people in the least restrictive setting. It doesn't have to be forced treatment versus the street, and it shouldn't be.

Instead of focusing on involuntary treatment, we should use the money we do have to feed the hungry, house the homeless, and provide community mental health treatment to those who want it.

Abbey Normal

ClinkShrink said...

Well said, Abbey.

Anonymous said...

Well I'm bipolar and I took drugs for many years. While it is true that I get depressed (but never manic or delusional) without drugs every few years being "stable" is in no way worth it. I went off all of my drugs 1 year ago and now I have a life that would never have been possible on drugs. I've been working at the same place for eight months now, I've even been promoted, I can date now, I volunteer and have hobbies, I even have friends. I'm actually happy for the first time since I went on drugs 6 years ago. If I had stayed on drugs I would still have no hope and no future. Even if I end up on the street of something it is worth it to have a chance to live my life. This is something I don't think normal people can understand.

Sunny CA said...

I heard a lot about that book when it was first released including interviews with the author. I decided it would give me high blood pressure, so it is not worth it to me to read it. I disagree with the author's conclusions.

I agree with Abbey Normal. Why not provide safe housing for people instead of forcing them to live in a state hospital?

Who would the intended beneficiary be if we locked up all the "mentally ill" in state hospitals? Is this for the good of "society" or the good of the mentally ill? What would be the criteria? Would you force people into state hospitals who have had (or are having) a single, first psychotic episode? What about individual freedom?

I would rather die or live on the street than be forced to stay for life on a psychiatric ward, myself. I am glad I did not end up in jail rather than a hospital, though. Who knows what may have happened?

I also agree with the previous Anonymous. Being on psych drugs was awful. They took away my quality short-term memory, my ability to reason and my ability to feel. I think the drugs ought to be called "Inabilify" and "Zy-wreck-sa".

Anonymous said...

yes. all this talk of what we should do has got me thinking that it is time to go off the meds even tho they have kept me stable. i have lived long enough and i am ready to go down whatever path i face now so long as it does not involve incarceration in a ward of any kind. never found therapy any help as most shrinks i have known have as many if not more junk in their closets that they are unwilling to deal with and i have paid a price for that. the segway came and went . big deal. the iPad came. i don't care. i have seen some of the world. the rest, i don't really care to see. i have seen enough in my head. its been a trip. if i live another 20 years, so be it. if i jump off a cliff in six months, thats okay too. to h with the drugs and the docs and what i HAVE to be and do and feel.

BPLadybug said...

Thank GOD for medication. It has been a blessing for me. And I work, have a family, a life. There is a big difference between being well medicated and OVER medicated. If you feel numb, have no emotions, if you have lost your ability to feel, to reason than you need a medication adjustment or a med change.

There is NOTHING romantic about going off medications, jumping off of bridges or cliffs. Perspective, do some therapy and gail some perspective.

Unknown said...

I thought the book was well written and eye opening. Mental illness runs deep in my family. I don't think that there is any easy answer to any of these problems. If there were, it's likely that there would have been no book I the first place. I also very much agree with the part about giving every individual, regardless of their past or their crimes, a safe environment with others that care about them. When I say that, I mean actually care... care like these were their own family members.
I think that there are pros and cons to asylums. However, Earley mentions: "a real asylum - defined in the dictionary as being a safe place," this is the definition I hope would be used in real life.

The previous asylums were dismal places and the jails should not be a boarding house. I would hope that wet can find an answer that treats all people as humans ... after all, that's what we are.