The commissioner deals on a regular basis with people who cannot accept the fact that psychiatry has limitations. One especially important point is not widely recognized: The major mental illnesses of people in public mental health systems can sometimes be partly controlled, but they are chronic in nature and generally not susceptible to cure. Most people with symptoms of such chronic medical disorders as diabetes, cancer, and heart disease remain in the community with warm social support; yet the person who persists in exhibiting signs of mental illness causes almost unbearable distress to many citizens and thereby symbolizes the inadequacies of the mental health system. Many responsible community leaders believe that even the most seriously disabled mentally ill persons can be treated successfully in the state mental hospital and restored to the community to live independently and symptom-free indefinitely. Continued hospitalization, "crazy" behavior in the community, or return to the hospital after discharges are regarded as signs of the bad judgment of the officials of the system. The absence of any treatment methods that could achieve total and permanent restoration to mental health tends to be ignored by these critics. They apparently believe that if the agency were better managed, had more doctors and other treatment personnel (or perhaps better ones), or had more money, it could cure the incurable.
The Homeless Mentally Ill
The mental health commissioner is also expected to solve some of the most difficult issues in our society. The case of the homeless mentally ill presents the quintessential example of unrealistic expectations, since the mental health system actually gets much of the blame for the problem.
There is no escaping the media reports of the desperate plight of the nation's homeless-people who survive by panhandling and eating out of garbage cans, who huddle over subway grates in the winter and sleep in doorways and under bridges. Not surprisingly, a significant percentage of these people have symptoms of a mental illness. In fact, the same can be said about 19 percent of the general population. This association between homelessness and mental illness has led to widespread publicity attributing the problem of homelessness to state mental health agencies and their policy of de institutionalization. The implication is either that these people did not stay in the hospital long enough to be cured or that they should be gathered up and put into mental hospitals-which are, after all, residences of a sort.
The logic of the connection between deinstitutionalization and homelessness is faulty. Although about 25 to 40 percent of these people have a history of mental illness, it does not follow that the problem was created by the mental health system.25 It is true that in the 1950s state hospitals served as warehouses for thousands of people who had no other place to live. Yet several contemporary factors beyond the control of the mental health commissioner, including both laws and professional standards, make it inconceivable that state hospitals could ever be used in that fashion again.
Medications now enable the vast majority of mentally ill people to live outside of hospitals. Mental illness does not imply an automatic need for hospitalization any more than does physical illness. As in chronic physical disorders, hospitalization is required only when symptoms are acute and when medical supervision and continual nursing care are necessary. It is not only clinically improper to house mentally ill people in hospitals when they do not need hospitalization; it would also break the budget of most states. With accreditation of state hospitals now requiring staffing levels that may cost several hundred dollars per patient day, it would make little sense for the state mental health agency to herd homeless people into hospitals.
Even if a commissioner were disposed to attempt such a solution to the problem of the homeless mentally ill, the law would impose a formidable barrier. Since the early 1960s, federal courts and state legislatures have modified commitment laws to mandate as a condition for involuntary admission to a state mental hospital both the presence of mental illness and a judicial determination that the patient is either ' 'gravely disabled" or exhibits behavior that poses a serious physical danger to the patient or another person. Even in the case of a homeless mentally ill person who requires hospitalization, a determination that the patient is "in need of care and treatment" (the previous standard for commitment) would not satisfy the current, more stringent legal criteria. In the continuing conflict between individual freedom and the protection of health by the state, freedom currently commands a very high priority.
State mental health agencies do attempt to provide psychiatric treatment (although not necessarily in a state hospital) to homeless mentally ill people, to the extent that they agree to accept such treatment and within budgetary constraints. But even when these people receive psychiatric treatment, they remain the' 'homeless mentally ill" because their illnesses, although perhaps improved, will endure and because psychiatric treatment cannot create a home for them. Neither can psychiatric treatment address some of the root causes of homelessness: poverty, social isolation, and lack of a human services "safety net."
Members of the homeless population often have serious medical and social as well as psychiatric problems. Substance abuse has always been a major contributor to their situation. The homeless also have poor nutrition, tend to be school dropouts, and lack job skills. How often, however, is homelessness identified as a medical problem, an educational problem, or a problem for the state public welfare agency, the vocational rehabilitation agency, or the housing authority? The mental health agency and its commissioner are often expected to absorb the criticism engendered by society's failure to meet the basic needs of its poor and disabled members.
The Dangerous Mental Patient
Accused of lack of diligence, the mental health system and its chief are also blamed for violent crime, or at least the violent acts of those who were previously institutionalized. Although it has been established that mentally ill people as a group are no more dangerous than other groups, the public has been conditioned by the media (including movies about mad killers) to believe differently. A person who was once in a state hospital and who later commits a violent act is routinely characterized as a "former mental patient," suggesting that the hospital and mental health agency are somehow responsible. The agency's psychiatrists are expected to know when a patient might become violent and then either to cure the patient before discharge or keep him or her locked up indefinitely. It is, of course, impossible for the agency to comply with these expectations. In the first place, as noted before, even the best hospital treatment cannot cure people of serious mental illness. Second, neither a psychiatrist nor anyone else can accurately predict the future behavior of another person, whether or not the person is mentally ill. Third, it is illegal to keep a mental patient locked up indefinitely in an institution solely because the staff believe the patient might someday exhibit dangerous behavior.
If a patient in a state hospital or special forensic hospital (for the "criminally insane") no longer meets the legal standards for commitment, the mental health agency is not simply allowed to release the patient; it is required to release that patient-even if he or she has previously committed a violent act. The agency's psychiatrists face a "catch-22" situation. If they continue the confinement of a patient who does not seem to be dangerous now because they think he or she might someday hurt someone, they face the wrath of the civil libertarians and patient-rights advocates. If they release the patient, they are certain to be denounced if the patient commits some violent act in the future. In the final analysis, patients will be discharged from both civil and forensic mental hospitals because they must be. Occasionally one of these people will commit a violent act. When that happens, the state mental health commissioner is likely to surface as the official who bears at least some indirect responsibility for the violent act.
The discovery by the media that "dangerous" people are being discharged can lead to harsh criticism of the mental health agency. Legislators and newspapers with a law-and-order agenda do not always distinguish between convicted criminals and patients who have not been convicted. Such patients have been found incompetent to stand trial or acquitted on the ground of insanity. When the state mental health commission authorizes the release of dangerous patients from forensic hospitals, as the law often requires, the commissioner must take the risk of being accused of endangering the public.
Deficiencies in the mental health system are also alleged in the case of particularly horrendous crimes such as mass or serial murders perpetrated by people who have never received psychiatric treatment. A better mental health system would presumably have identified potential criminals in advance, sent them to the appropriate kind of therapy, and prevented the tragic occurrences. Needless to say, no conceivable state mental health system could accomplish such a feat.
