Saving Seth

"Saving Seth" Continued...

Issue: "The Battle for Africa," Feb. 8, 2014

ARIZONA'S MENTAL HEALTH LAWS are considered some of the best in the nation, in part because of a 1981 class-action lawsuit, Arnold v. Sarn. Arizona is one of the few states that allow residents to be involuntarily (by court order) evaluated and treated for mental disorders if they are considered “a danger to self,” “a danger to others,” “gravely disabled,” or “persistently or acutely disabled.” Most states only allow involuntary treatment if the person is a danger to self and others—which bluntly translates to requiring violence before acting toward prevention, rather than proactively taking all measures to prevent it. 

The Geeslings were able to petition the courts to commit Seth involuntarily. Per Arizona’s law, the judge put him on court-ordered treatment for one year; but once the order expired, Seth stopped taking his medication. And so began the carousel: Hospital. Court. Home. Hospital again. Transfer to another hospital, then another. Home. A shortage of public psychiatric beds in the state meant hospital staff could only keep Seth long enough to stabilize him. At home he would stop taking his medication; symptoms would return, and he would be back at the hospital to start the cycle all over again. Deborah calls it a “revolving door system.”

The bed shortage is a nationwide problem. The Treatment Advocacy Center, a national advocacy organization, estimates that the nation is short 95,000 psychiatric beds. In 1955, 300 public psychiatric beds were available for every 100,000 people. America has lost 95 percent of those beds since then: Half a century ago states started deinstitutionalizing the mentally ill, releasing about 830,000 people into their communities.

Deinstitutionalization back then appealed to both civil-rights liberals seeking to “free” the mentally ill from lockdown institutions, and to fiscal conservatives looking for ways to cut budgets. In an era devoted to liberation, activists and novelists (such as Ken Kesey, author of One Flew Over the Cuckoo’s Nest, which became a much-lauded movie) argued that the mentally ill might be the sanest among us, and in any case treatment should be voluntary.

This massive social experiment worked for some higher-functioning patients, especially with the introduction of effective antipsychotic drugs such as chlorpromazine, which helped certain patients with schizophrenia to improve significantly. The introduction of Medicaid in 1965 and the expansion of other federal programs led state governments to ask, “What can we get Washington to pay?” Before such federal programs, state governments paid 98 percent of mental health costs. But state cost-cutters realized that by closing down psychiatric beds and forcing out patients, they could shift the financial burden onto the federal government.

Medicaid did not pay for state psychiatric hospital patients between the ages of 22 to 64, but it covered community-based services and also paid for inpatient psychiatric care in general medical hospitals. Those rules gave states incentives to push patients into outpatient programs and general medical hospitals (usually ill-equipped for long-term psychiatric care). By 1986, 42 percent of mental health expenditure was on inpatient care, and by 2005 that had dropped to 20 percent.

Medicaid brought some benefits, including adoption of safer and more effective antidepressants and antipsychotic drugs. But some researchers believe it also tilted public mental healthcare toward Medicaid-covered people and services, as states aggressively pursued policies and programs that met Medicaid match requirements. State agency roles dwindled to financing and adopting reimbursable Medicaid practices that often did not fit individual patient needs.

One problem quickly emerged: Once the patients were liberated, who would make them take their medicine? Homelessness spiked. Prison populations swelled. Public resources, spent on law enforcement and emergency services, surged. D.J. Jaffe, executive director of Mental Illness Policy Org., told me, “Under the guise of protecting civil liberties, we have more people incarcerated for mental illness than ever before. Civil liberties? Freeing people from their psychosis, from their hallucinations, is the greatest liberty you can provide them.”

PERPLEXING ISSUE: The closed Central State Hospital in Milledgeville, Ga., which originally opened in 1842.
Associated Press/Photo by Jaime Henry-White
PERPLEXING ISSUE: The closed Central State Hospital in Milledgeville, Ga., which originally opened in 1842.
Seth with his parents and one of his brothers.
Seth with his parents and one of his brothers.
Jared Loughner’s mug shot.
Pima County Sheriff’s Forensic Unit/Getty Images
Jared Loughner’s mug shot.
‘From the beginning, my son is the hero here. He’s the one who’s suffering, and we’re the ones watching him suffer … but as much as God has allowed the suffering, every step of the way, He’s provided.’
Charlie Leight/Genesis
‘From the beginning, my son is the hero here. He’s the one who’s suffering, and we’re the ones watching him suffer … but as much as God has allowed the suffering, every step of the way, He’s provided.’

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WHEN SETH WAS FIRST HOSPITALIZED in an adolescent psychiatric hospital, the clinic discharged him after one week, saying, “We think he may be bipolar.” His parents stood confused, helpless, and scared. “So ... what do we do? What now?” they asked. “Go find him a counselor,” the psychiatrist and a caseworker advised. The Geeslings drove back home feeling as though they were “groping in the dark,” Deborah recalled. Meanwhile, Seth steamed with bitter resentment in the backseat, certain his parents were the enemies. They had lost his trust. 

Jaffe says the top-recurring question from parents is, “My son doesn’t realize he has a mental illness. What do I do?” Nor do adult children with psychotic parents know what to do. Yet individuals without insight into their mental illness—a clinical condition called “anosognosia”—are the greatest danger to themselves and society. Many national organizations talk a lot about getting rid of stigma regarding the mentally ill, but the most seriously mentally ill are too sick to care about stigmas, or even to realize they’re sick. They need immediate, direct treatment—medications, hospital beds, and assisted transition to court-ordered outpatient care—but often don’t get it.

—This was part one of Sophia Lee’s investigation. In part two she writes about a young woman dealing with bipolar disorder, a young man whose condition tortures his mother and himself, and what government and churches are doing—and not doing.

The sources for the information in the graphic are the National Institute of Mental Health, National Alliance on Mental Illnesses, National Alliance to End Homelessness, and Treatment Advocacy Center.


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