A Schizophrenic on Death Row

The Opinion Pages
The New York Times
Originally published Ocotber 17, 2012

The Florida Supreme Court decided on Wednesday that the state can proceed with the execution next week of a 64-year-old inmate named John Ferguson. His lawyers immediately said that they will ask the United States Supreme Court to stay the execution and to review the case on grounds that Mr. Ferguson is mentally incompetent and that executing him would violate his constitutional rights as defined by the court in two earlier decisions.

The court must review the case. At issue are not only Mr. Ferguson’s life but also two differing interpretations of what constitutes competence: one Florida’s, the other the Supreme Court’s.

The entire story is here.

In Deal, Hundreds of Mentally Ill People Will Leave Confinement of Nursing Home

By Anemona Hartcollis
The New York Times
Published September 12, 2011

Hundreds of mentally ill people who have been confined to nursing homes, sometimes in prisonlike conditions, would move to apartments or other housing within three years under a legal settlement with New York State.

The settlement resolved a case that was filed in Brooklyn federal court in 2006 and that accused the state of violating the spirit of its own longstanding rules for housing mentally ill people.

In researching the case, the plaintiffs found that psychiatric centers and nursing homes had developed “turnaround agreements, which essentially were written agreements to transfer patients back and forth,” Veronica S. Jung, senior staff attorney for New York Lawyers for the Public Interest, which helped to represent plaintiffs, said Monday.

“This certainly raises broader, troubling questions about the role of nursing homes, and their financial stakes, within the mental health care system,” Ms. Jung said.

The settlement came as the judge in the case, Brian M. Cogan, set a trial date for early October, Ms. Jung said.

“It did seem pretty clear that the specter of going to trial in the next few days probably motivated the state to move more quickly in negotiations,” Ms. Jung said. The state has agreed to pay $2.5 million in legal fees and costs to the plaintiffs’ counsel.

Andrew J. Zambelli, counselor to Gov. Andrew M. Cuomo, said the state had settled the case because “it just jibed with our kind of policy viewpoint — care for the vulnerable, into the community, using money appropriately.”

Under longstanding legal principle in New York and elsewhere, the mentally ill cannot be confined unless they are considered a threat to themselves or others, and should be housed in the least restrictive setting appropriate for their needs.

Under the terms of the settlement, the Cuomo administration has agreed to reform the process used to assess whether patients are capable of living in the community and want to live there. The state has also promised to hire independent contractors who would be trained to make the assessments.

The entire story can be found here.

Nation's Jails Struggle With Mentally Ill Prisoners

By NPR staff

Three hundred and fifty thousand: That's a conservative estimate for the number of offenders with mental illness confined in America's prisons and jails.

More Americans receive mental health treatment in prisons and jails than in hospitals or treatment centers. In fact, the three largest inpatient psychiatric facilities in the country are jails: Los Angeles County Jail, Rikers Island Jail in New York City and Cook County Jail in Illinois.

"We have a criminal justice system which has a very clear purpose: You get arrested. We want justice. We try you, and justice hopefully prevails. It was never built to handle people that were very, very ill, at least with mental illness," Judge Steve Leifman tells Laura Sullivan, guest host of weekends on All Things Considered.

A failing system

When the government began closing state-run hospitals in the 1980s, people with mental illness had nowhere to turn; many ended up in jail. Leifman saw the problem first-hand decades ago in the courtroom. When individuals suffering from mental illness came before him accused of petty crimes, he didn't have many options.

"What we used to do, which I tell people was the definition of insanity [...] was they would commit an offense, the police would arrest them, they'd come to court, they'd be acting out so we would order two or three psychological evaluations at great expense, we would determine that they were incompetent to stand trial and we'd re-release them back to the community and kind of held our breath and crossed our fingers and hoped that somehow they'd get better and come back and we could try them," he says.

Instead, many disappeared and got re-arrested. Sometimes within minutes.

"They'd walk out the door, they were ill, they'd act out, because [the jail] is next to the courthouse there are several officers out there, and they'd get re-arrested," he says.

Not only was the system inefficient, it was costly as well. When Leifman asked the University of South Florida to look at who the highest users of criminal justice and mental health services in Miami-Dade County, researchers found the prime users were 97 people, individuals diagnosed primarily with schizophrenia.

"Over a five-year period, these 97 individuals were arrested almost 2,200 times and spent 27,000 days in the Miami-Dade Jail," Leifman says. "It cost the tax payers $13 million."

More information can be found here.

Blog Comment on British Psychological Society on DSM-5

Dr. Will Meek is a psychologist practicing in Vancouver, WA. He writes regularly about mental health on his blog: Vancouver Psychologist

Some of you may be following the development of the forthcoming fifth revision to the Diagnostic and Statistical Manual of Mental Disorders (DSM), the major book used for psychiatric diagnosis. There has been a lot of criticism due to the secrecy of the process this time around, but the British Psychological Society (BPS), the major mental health organization in the UK, is taking an even more interesting and refreshing angle: criticizing the entire current framework of diagnosis.

The DSM takes a medical approach to diagnosis. In short, this means that a ‘patient’ is assumed to have an underlying ‘pathology’ that manifests as various ‘symptoms’ that are assessed to make a ‘diagnosis’ and then apply a ‘treatment’ to said diagnosis. This approach basically makes various human conditions into ‘illnesses’ that need ‘interventions’ like medication or cognitive behavioral therapy. In a recent paper, BPS has criticized this framework as harmful to individuals and the public.

“The Society is concerned that clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation. (p.1)”

“We believe that classifying these problems as ‘illnesses’ misses the relational context of problems and the undeniable social causation of many such problems. For psychologists, our well-being and mental health stem from our frameworks of understanding of the world, frameworks which are themselves the product of the experiences and learning through our lives. (p.4)”

As a practicing psychologist who also teaches a class on diagnosis for master’s level therapists, I could not be more excited reading this paper. BPS essentially takes a more humanistic and social constructivist approach to the problems of living. The benefits of this include reducing stigma, a larger focus on the interpersonal dimensions of mental health, and normalizing the experience of having problems during life.

Cheers to you BPS, now if only your American counterparts would get the message…

Psychiatric Bed Study in England

Link Established Between More Patients Being Detained In Hospitals Involuntarily And Fewer Mental Illness Beds

Medical News Today

According to a recent study published on bmj.com, in the last 21 years hospitals across England have seen a tremendous increase in the number of patients being detained for mental illness while concurrently there has been a reduction in the number of beds for patients with this disorder. The study was conducted by experienced researchers from the Warwick University, University of London & Queen Mary, and the Newcastle University.

The research has revealed that the reduction in the number of beds for mental illness, which was actually done as part of a policy to maximize the community alternatives for hospital stay, had a direct correlation with the increasing number of involuntary patient admittance to psychiatric centres.

In recent years, with an objective to deinstitutionalise the care of the mentally ill in developed nations, the number of beds for mental illness have been cut back. To achieve this objective, several changes have also been made to the legislation in the UK such as the introduction of the Mental Health Act 1983. Despite efforts such as crisis resolution home treatment, assertive outreach and availability of community mental health teams, a number of countries have seen an increase in the involuntary patient admittance to psychiatric centres.

The increasing use of compulsory detention is quite displeasing among both, the patients and the healthcare providers. Huge expenses involved with in-patient care also make it a source of concern to service providers and commissioners.

The analysis was performed by scientists based on the data available publically in the NHS Information Centre and the Department of Health. The researchers took a note of the hospital activity statistics on the NHS mental illness bed provision and involuntary patient admittance rates, between 1988 and 2008.

It was found that for these two decades, the involuntary patient admittance rates increased from 40.2 % to 65.6 % per 100,000 adults/ year, while at the same time there was a decrease of 62 % in the number of beds for mental illness per 100,000 adults.

When a time delay of one year was applied, a substantial association between these variables was found, with bed reductions preceding the number of involuntary patient admittance. Ultimately, in the following year, the results showed that there was one extra involuntary patient admission for every two beds closed.

The information about the clinical reasons for admissions were not mentioned in the dataset that was analysed; however the authors of the study have stated that it is unlikely that the increase reflects "an otherwise unreported dramatic increase in the prevalence of severe mental disorders in England."  

The researchers conclude,

We emphasise that this paper does not suggest that bed closures are intrinsically inappropriate. This strategy may well be a reasonable course of action; but the bed mix needs to be examined more closely and the rate and consequences of bed closures may need to be considered more carefully. Overall, this study provides important evidence for the need to anticipate the effects of bed closures.

Dealing With the Depressed or Dangerous

SAN FRANCISCO — How far can colleges go to stop students who are threatening to commit suicide?

It’s a fundamental question for college and university officials who work in the fields of student affairs, counseling and mental health -- and for the lawyers who may have to deal with the aftermath, and sometimes see mental health issues as a minefield of potential litigation.

At a session Tuesday here at the annual meeting of the National Association of College and University Attorneys, experts in legal affairs and mental health urged colleges to do all they can to get students who are threatening to harm themselves into treatment, or to get them off campus if the situation continues to deteriorate.

In the past decade, the number of college students with severe mental health issues has climbed. The development is often attributed to better early intervention and psychiatric drugs that enable students to function normally and attend college who wouldn’t have been able to do so in the past. “That’s a wonderful thing,” said Paul Lannon, an outside lawyer for several New England colleges who moderated the session.

But the increase has also been accompanied by several high-profile lawsuits, and the conclusion colleges and universities draw from those could be “damned if you do, damned if you don’t.”

After a Massachusetts Institute of Technology sophomore, Elizabeth Shin, committed suicide by setting her dorm room on fire in 2000, her family sued MIT for $28 million. They argued that the university’s counseling system failed Shin, who had a documented history of depression and threats before she killed herself. The suit was eventually settled confidentially.

In 2006, Jordan Nott, a former student, sued George Washington University, claiming that he had been forced to withdraw from the university after seeking help for depression. Nott also reached a confidential settlement.

The federal government has intervened in some similar cases through complaints students filed with the Department of Education’s Office of Civil Rights, which has come out against universities who force students to leave campus because of mental illness, including a case at Bluffton University, in Ohio, in 2004.

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The entire story can be found here.

Thanks to Ken Pope for this article.