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[Bernard Harcourt, guest-blogging, April 30, 2007 at 9:48am] Trackbacks
On Mental Health Commitments and the Virginia Tech Shooting:

Was the tragic incident at Virginia Tech the result of a failure of Virginia's mental health system? Slate recently posted Seung-Hui Cho's commitment papers and they are revealing: the magistrate who heard Cho's case determined that he was "an imminent danger to himself as a result of mental illness," but determined that there were "alternatives to involuntary hospitalization."

After the shooting, Sally Satel at AEI argued that Virginia needs to reexamine its involuntary treatment laws and adopt a lower threshold for commitment, more in line with states like Arkansas and Hawai'i. Others, like Brian Jenkins at RAND, contend that the tragedy probably could not have been prevented and might not have a solution.

It's impossible to make sense of the debate, though, without understanding the extent to which we've dismantled our mental health system in this country. Brick-by-brick, cell-by-cell, we deconstructed what was once a massive mental hospital complex and built in its place a huge prison.

The sheer magnitude of transformation is absolutely remarkable. It is visually shocking — especially given the exponential rise in incarceration in this country in the past thirty years. The following figure gives a snapshot. It shows the aggregate rate of institutionalization in the United States for the period 1934 to 2001, with disaggregated trend lines for mental hospitalization on the one hand and state and federal prisons on the other.

FIGURE: Rates of Institutionalization for Residents in All Mental Institutions and State and Federal Prisons in the United States (per 100,000 adults)

Although our current rates of imprisonment in state and federal prisons are extraordinarily high, the level of total institutionalization (in prisons and asylums) was higher during the 1940s and 50s.

We all know that prison populations skyrocketed nationwide beginning in 1970, rising from under 200,000 persons to more than 1.3 million in 2002. That year, in 2002, our prison rate exceeded for the first time the 600 mark (600 inmates per 100,000 adults) — by far the highest rate and raw number of incarcerated persons in the world.

But what is far less well known is that the United States as a whole institutionalized people at even higher rates in the 1940s and '50s. If you look at rates of persons in mental hospitals and prisons per 100,000 adults, in the period between 1935 and 1963 the United States consistently institutionalized at rates above 700 per 100,000 adults — with highs of 778 in 1939 and 786 in 1955.

In a recent study, I collected state-level data on mental hospitalization for the twentieth century, and my findings are staggering. For one thing, there was a wide range of institutions. In addition to state and county public mental hospitals, there were public and private institutions for "mental defectives and epileptics" and for "the mentally retarded," psychiatric wards in general and VA hospitals, "psychopathic hospitals," city hospitals, and private mental hospitals.

There was also an entire parole system for persons institutionalized in mental hospitals and the parole numbers were non-negligible: on December 31, 1933, for example, 46,071 mental patients were on parole or otherwise absent, representing almost 10 percent of the total institutionalized patient population of 435,571.

One of the most perplexing things I discovered is that there is a strong statistical relationship between aggregated institutionalization (in asylums and prisons) and serious violent crime. Using state-level panel regressions spanning the entire period from 1934 to 2001, including all 50 states, and controlling for economic, demographic, and criminal justice variables, I found a large, robust, and statistically significant relationship between aggregated institutionalization and homicide rates. The findings are not sensitive to weighting by population and hold under a number of permutations, including when I aggregate jail populations as well.

I say "perplexing" because the populations in asylums and prisons were very different: residents in mental hospitals were more white, female, and older than our current prison populations. In 1966, for example, there were 560,548 first-time admissions to mental hospitals, of which 310,810 (55.4%) were male and 249,738 (or 44.6%) were female. In contrast, new admittees to state and federal prison were consistently 95% male throughout the twentieth century. There were also sharp differences in racial and age compositions.

Because of these sharply different populations, it's not clear yet what to conclude from my study — and it's far too early to draw public policy implications. But a few things are clear.

The first is that we should not be surprised that there are so many persons with mental illness behind bars today. We deal with perceived deviance differently than we did in the past: instead of getting treatment, persons who are viewed as deviant or dangerous are going to jail rather than mental hospitals.

The second is that we should not be surprised that our mental health systems are in crisis today. The infrastructure is simply not there. This is evident in states across the country where persons with mental illness are being housed in jails rather than treatment facilities.

What is also clear is that Seung-Hui Cho probably would have been institutionalized in the 1940s or 50s and, as a result, the Virginia Tech tragedy may not have happened. According to the New York Times, the director of the campus counseling services at Virginia Tech said of Cho: "The mental health professionals were there to assess his safety, not particularly the safety of others." It's unlikely we would have taken that attitude fifty years ago.

But the problem is, we would also be institutionalizing another huge swath of humanity — and it's simply not clear how many of those other lives we would be irreparably harming in the process.

The classic texts of social theory from the 1960s — Erving Goffman on Asylums, Gerald Grob on The State and the Mentally Ill, David Rothman on The Discovery of the Asylum, Michel Foucault on Madness and Civilization, Thomas Szasz on The Myth of Mental Illness, Michael Ignatieff on A Just Measure of Pain, and many others — describe in chilling detail how closely mental institutions began to approximate the prison and the "total institution." These critical writings should remind us of the other price that society pays when we commit and institutionalize each other.

Frank_B:
I think the most arresting graph is the one on page 23, showing homicides rise as institutional confinements drop in the late 1960s.

Our high rate of penal imprisonment is widely-cited, but your study makes me wonder whether that's a fair picture. How do US rates of total institutionalization compare to the world?

I suspect (given how we've dismantled mental health infrastructure), that we're somewhat closer to the rest of the industrialized world.
4.30.2007 11:09am
Nate F (www):
This is a very interesting post, thank you. I have a few comments. First, I am not sure that the dismantling of the old mental health system was entirely a bad thing. Under that system, it was very easy for someone to have you committed under certain circumstances whether you deserved it or not. Something along those lines happened to my great uncle, I am told.

Second, I am not sure restoring a system like the old one wouldn't exacerbate the mental health stigma, which is already a huge problem. As a teenager, I was periodically deeply depressed, but I learned quickly that actually talking about it, even with some of the people I considered good friends, often made people look at you like you were a leper. If we go back to saying that those with mental problems ought to be in state care, I doubt that will help matters.

I know you aren't necessarily advocating a return to that system, but these things are worth keeping in mind.
4.30.2007 11:19am
American Psikhushka (mail) (www):
I agree with Nate F., even with the current system there are still people that are falsely committed. We don't need false commitments, and false lobotomies (that barbarous nonsense is coming back, by the way), and all the other crap that used to happen any time someone wants to steal from or screw over a spouse or relative. (Remember they had the lovely practice of sterilizing some people as well.) As the founding fathers believed, better some kooks roaming around than innocent people having their rights violated.

Along those lines, does anyone know how Colin Ferguson, the LIRR shooter, got the gun? I tend to doubt it was purchased legally, but I wanted to confirm this.
4.30.2007 11:37am
Justin (mail):
My father, who is a psychiatrist, once told me that he read a study that said over half (and it was substantially over half) of all prisoners in the US were in jail due to some behavior stemming from some mental illness (and not the contraversial designation of any "antisocial" disorder). While by far the most common mental illness was drug addiction, others (ranging from bipolar disorder to schizophrenia) were prominent as well. My dad (a liberterian) said it was amazed that the solution wasn't "treat the patient." Since that conversation, I've always thought it a good idea to bring a class action requiring prisons (under the DeShaney exceptions) to diagnose and treat mental illnesses - both as a human right and an effective way to reduce recidivism.

That being said, I think its obvious that prisons *are* becoming the new commitment centers for mentally troubled people without resources.
4.30.2007 11:37am
Justin (mail):
If not made obvious from above, I think the best solution to EV's quandry is to focus not on committing people with mental diseases (sort of like the way we do with those people with the terrible mental illness of pedophilia), but by reforming the *prison* population to help treat mental health patients. While the VaTech shooter wasn't someone whose previously been through "the system," most murders are committed by people who have been.
4.30.2007 11:42am
Justin (mail):
According to both this and my own recollection, the LIRR gun was obtained legally.

http://www.thegunzone.com/black-talon.html
4.30.2007 11:46am
Ron Hardin (mail) (www):
The mental health hospitals were dismantled when sociologist Erving Goffman published _Asylums_ in the 60s, and it was badly misread as showing the system to be a fraud.

He was studying institutions in general, and how they all work, and produce roles and so forth, and meant it to be very general using mental institutions only as a model of a total institution.

The sort of lesson he in fact draws can be seen in some excerpts I liked , far from suggesting that they be closed down.

But closing them down fit the temper of the times, so that's what happened.
4.30.2007 11:59am
Eric Rasmusen (mail) (www):
Great topic for a paper! I suggest you look carefully at males aged 14 to 30, since that's where so much of the crime is. A separate effect would be if inner cities become more disorderly and unattractive generally, even though the released people were not the ones committing the crimes.
4.30.2007 11:59am
pete (mail) (www):
So far no one has mentioned where a large percentage of the mentally ill end up: homeless on the street. These people often have regular interactions with police, but many do not commit crimes serious enough to land them in prison.

I regularly encounter schizophrenics and other severely mentally ill people in my work as a public librarian. From people who think the government is shooting them with microwave rays from satellites to one guy who thinks he is the king of France. These people can not take care of themselves (that is often why they are homeless), but are usually not an immediate danger to others. And because of their mental illnesses they are not going to voluntarily commit themselves, even if the treatment facilities were available.

That does not count the number of mildly retarded people among the homeless, although I suspect they number far less than the insane.
4.30.2007 12:06pm
PersonFromPorlock:
It's interesting to note on the graph that the incarceration rate in prisons doesn't rise above historic levels until about 1980, despite the near emptying of mental institutions by then.

My best guess is that the truly dangerous mental inmates were released last, towards the late '70s, and promptly committed crimes that put them into the prison system. From this, I draw two lessons: first, that the bulk of institutionalized mental patients posed no threat to society; and second, since we're now approaching historic institutionalization rates again, this time in prisons alone, that we are putting in prison people who would formerly have been put in mental institutions and who pose mainly a threat to themselves, if that.

Of course, it's also possible that there's been a real rise in crime unrelated to the emptying of the asylums and that this graph is a chimera.
4.30.2007 12:15pm
byomtov (mail):
Using state-level panel regressions spanning the entire period from 1934 to 2001, including all 50 states, and controlling for economic, demographic, and criminal justice variables, I found a large, robust, and statistically significant relationship between aggregated institutionalization and homicide rates.

I'm curious as to what time increments were used, and whether you explored the relationship between lagged homicide rates and institutionalization.
4.30.2007 12:27pm
Zubon (www):
I believe many commenters are not considering the following paragraph:
I say “perplexing” because the populations in asylums and prisons were very different: residents in mental hospitals were more white, female, and older than our current prison populations. In 1966, for example, there were 560,548 first-time admissions to mental hospitals, of which 310,810 (55.4%) were male and 249,738 (or 44.6%) were female. In contrast, new admittees to state and federal prison were consistently 95% male throughout the twentieth century. There were also sharp differences in racial and age compositions.

It is not simply the case that we have emptied the asylums into the prisons. That is a part of the story, but the incarcerated groups do have large differences.
4.30.2007 12:34pm
Skeptical:
This is a very difficult thing to make any conclusions about, as so many other social changes occurred at that time.

For example, consider that the fall in institutionalization in mental hospitals occurred during the civil rights movement and the end of segregation. It may be that the end of mental hospitals had little effect, while the end of segregation had a huge effect on crime rates.
4.30.2007 12:48pm
Brett Bellmore:
Perhaps the formerly institutionalized mentally ill just made such great victims once they were released, that they produced a greater "demand" for violent crime? That would explain why releasing them would drive up the violent crime rate, without their being the ones committing the crimes.
4.30.2007 12:49pm
Frank_B:
I agree with others who dislike the old days of unjust commitment, but we're so far from that right now that it's absurd worry. We live in an age when family members of a dangerously ill individual can beg the state to accept them for treatment but be denied. Few resources are given to mental health such that relatively high standards of imminent danger must be proved.

Crime is often the best way individuals can get some semblance of treatment. I find this less-than-ideal.
4.30.2007 12:51pm
PatHMV (mail) (www):
I was just about to point out exactly what Zubon pointed out. That fact should serve as a powerful reminder that correlation does not mean causation (as the author of the study quite properly notes, but many commenters seem to be overlooking).

There were a lot of things going on in our society in the 1960s and 1970s, all at the same time. The increased crime rate and the decreased involuntary commitment rate are probably separate manifestations of the various changes taking place at that time. The same humanitarian considerations and belief in the power of "rehabilitation" and "treatment" which led to shutting the mental health hospitals also brought us public housing "projects" which quickly became festering concentrations of crime, more permissive parenting, greater tolerance for drug use, less restrictions on children's behavior in school, among others. It is not inconceivable that these changes, unleashed by the same motivations as caused the asylums to close, also caused the increase in crime. The two effects (increased crime and decreased commitments) may appear at the same time because they share causative factors, rather than because one caused the other.
4.30.2007 12:59pm
Clayton E. Cramer (mail) (www):
One of the trade-offs seems to be having more people wandering the streets who are a danger to themselves and to others, or having a safer society. We don't have to go back to 1955 in our commitment laws to move the balance back. California, for example, set the direction for the rest of the country when it passed the Lanterman-Petris-Short Act in 1967. The requirements for involuntary commitment were that you either be:

1. "Gravely disabled": not be able to obtain food, shelter, or clothing (and gifts or begging qualified as able to obtain).

2. Be found incompetent to stand trial for murder or some other felony that involved either success or an attempt at great bodily injury to someone else. See Cal. Welfare &Institutions Code § 5008(h).

In practice, until you kill someone, or get darn close to it, a psychotic person gets away with a lot--or is perhaps not recognized as mentally ill, and just goes to jail for a short period of time. There's a bit of case law on the subject, and while it generally follows what the statute requires, the statute itself went too far in the opposite direction from the bad old days, when yes, people who were merely eccentric got locked up.

Still: how many mass murders--and "little" murders like this one are you prepared to tolerate in exchange for the current system?
4.30.2007 1:03pm
scarhill:
If you had shown me just the prison rate line from Prof. Harcourt's graph, I would have attributed most of the rise to the "War on Drugs". I wonder if that is part of the explanation for the different compositions of the two populations.

Suppose that releasing a large number of people from mental hospitals increased demand for illegal drugs significantly, both because some of those released were addicts and others used illegal drugs to self-medicate their mental illness. That increase in demand then led to greatly expanded illegal supply and distribution networks. Those networks, along with the crime and social disorder they engendered, brought the "War on Drugs".

I'm not sure how to turn that "just-so story" into a testable hypothesis, but I'd be interested to hear what Prof. Harcourt and others here think.

Jim
4.30.2007 1:04pm
Clayton E. Cramer (mail) (www):
PatHMV writes:

The same humanitarian considerations and belief in the power of "rehabilitation" and "treatment" which led to shutting the mental health hospitals also brought us public housing "projects" which quickly became festering concentrations of crime, more permissive parenting, greater tolerance for drug use, less restrictions on children's behavior in school, among others.
While I generally agree with your point--that perhaps what we are seeing is as much liberalism and its filthy consequences as deinstitutionalization--the fact is that we have a lot of murders in this country that are clearly the result of making it difficult to lock up people who are mentally ill until they kill someone, or darn close to it. Most of the gun mass murderers in recent decades--and a lot of the less well-known murderers who used other weapons, and thus had lower body counts--had serious, well recognized mental illness problems that had come to the attention of family, neighbors, and police. Laurie Dann, for example. Patrick Purdy. James Huberty. Russell Eugene Weston, Jr. John Hinckley. Buford Furrow. Those are just the names that you likely know because they used guns. There are lots of "little" murders, such as Joshua Rudiger, who was slashing the throats of homeless people, and told police on his arrest that he was a 2600 year old vampire, and they couldn't do anything to him.
4.30.2007 1:24pm
Clayton E. Cramer (mail) (www):

Suppose that releasing a large number of people from mental hospitals increased demand for illegal drugs significantly, both because some of those released were addicts and others used illegal drugs to self-medicate their mental illness. That increase in demand then led to greatly expanded illegal supply and distribution networks. Those networks, along with the crime and social disorder they engendered, brought the "War on Drugs".
Adding to the complexity of the problem:

1. Increased drug abuse leads to increased mental hospital admissions because it increases mental illness.

2. Urbanization increases mental illness as well.
4.30.2007 1:29pm
Sizegenetics (mail) (www):
Yes I agreed with you. Urbanization increase mental illness or so called depression. We should be understanding with these patient. What they is most is our love and support.
4.30.2007 1:52pm
Eric Rasmusen (mail) (www):
I took a quick look at the paper, and here are some thoughts:

1. In the time series, there are roughly 5 periods:

A. Murder declines, crime and jails+asylums (call them "lockups"
) are flat.

B. A long period when both murder and lockups are flat.

C. A transition period when murder rises to a new plateau and lockups fall drastically.

D. A long period when murder bounces around on its plateau and lockups are first flat and then rising.

E. 15 years when murder falls and lockups rise.

The murder-lockups inverse correlation is really based on something like 2 useful data points. Murder is rising in the 60s while lockups are falling. Murder is falling in the 90s when lockups are rising. The autocorrelation correction helps adjust for that, but somehow it doesn't seem satisfactory. Neither is my vague objection, but just looking at the time series without thinking about the reality, it looks like two states of the world with slow adjustment to shocks that move between them.

2. There is another regression you absolutely must do: regress murder on lockups, prison, and asylums all in one regression. That will separate out the effects. Standard economic theory says prison will reduce crime. That explains the 60s and the 90s. What you are investigating is whether an even better explainer is the total number of people in confinement. Thus, you need to put both things in the same regression to see which is the "true" explainer and which is mere correlation.

3. A breakdown by type of mental problems would be interesting. I'd expect someone who is moderately feeble-minded to be involved in more crime than someone who is depressed.

4. A good next paper would be an investigation of why there was a switch in the 70s from asylums to prisons (I guess both were emptying in the 60s). It is especially odd in light of the modern health fetish-- you'd think we'd be blaming medical conditions for everything and using hospitals instead of prisons.

5. I like writing innovations, but your informal intro doesn't quite work. Do keep the data time series point, but tone down the storytelling.

6. Spending on police is probably a better correlate of crime than unemployment
4.30.2007 2:04pm
whit:
i realize correlation =/= causation but DAMMMMN

fwiw, i CONSTANTLY deal with people (usually family members) who want me to take a mental into protective custody (we call them "invol's")

in most cases we can't. gotta have that whole "imminent danger" thang. batsh*t crazy does not count.

like everything else - it's a balance.

the pendulum probably has swung a bit too far on the side of NOT taking these people into treatment.

i've probably invol'd near 100 people total, and the vast majority are let out within a few hours, with a prescription.
4.30.2007 2:18pm
Houston Lawyer:
I strongly suspect that many of the white people who were formerly institutionalized now take drugs that control their mental problems. The incarceration rate most closely tracks the rate of illegitimate births in this country.

Under the current system, we wait until those who we know suffer from a mental illness commit a crime before we lock them up. Just two weeks ago, my ex-wife's best friend lost her son to suicide. He wouldn't take his meds and they couldn't force him to.
4.30.2007 2:25pm
Clayton E. Cramer (mail) (www):

Yes I agreed with you. Urbanization increase mental illness or so called depression. We should be understanding with these patient. What they is most is our love and support.
It might be true of depression, but the study I linked to was looking at schizophrenia and other psychoses--not depression. Love and support don't help schizophrenics all that much.
4.30.2007 3:50pm
Flighterdoc (mail):
How does the federal HIPPA regulation affect the ability of a physician to report to the state that a patient has been committed?

As a physician, I doubt that I'd be the first to test a conflict between state and federal law
4.30.2007 3:51pm
emilyk007:
Merlin Scales owns a rifle shop, Rabbit Ridge Enterprises, in Ararat, Virginia. As a former chief of police, he too was horrified by the shootings at Virginia Tech but insists guns are not the problem...

You can read the article on this gun shop owner's perspective towards firearms at www.orato.com
4.30.2007 4:01pm
Clayton E. Cramer (mail) (www):

3. A breakdown by type of mental problems would be interesting. I'd expect someone who is moderately feeble-minded to be involved in more crime than someone who is depressed.
Psychotics are the biggest problem. Several studies of post-release crime rates found that more than half of the arrests were schizophrenics. One study in San Mateo County had released mental patients with an average of 9x the arrest rate of the general population for violent crimes--and 55x the arrest rate of the general population for murder.

4. A good next paper would be an investigation of why there was a switch in the 70s from asylums to prisons (I guess both were emptying in the 60s). It is especially odd in light of the modern health fetish-- you'd think we'd be blaming medical conditions for everything and using hospitals instead of prisons.
I'm writing a book on this right now. The short answer is that a number of rather influential people looked at the success of the military's psychiatric first aid stations for dealing with combat fatigue during World War II--where people who had no severe mental problems going into the military were put into the madness of combat, and had problems--meant that the same "community mental health treatment" approach would work with civilians, many of whom were psychotic. This was so clearly wrong that it was implemented in a series of federal government programs to encourage this approach, with both Medicare and Medicaid funding encouraging transfer of senile mental patients to private nursing homes and psychotics to community mental health centers.

Adding to the complexity was that a failure to adequately fund state mental hospitals during the Great Depression and World War II had created some genuine snake pits, but more importantly, created a perception that all state mental hospitals were at best warehouses. A weird coalition came together that decided to move as many people out of institutions as possible. While this worked well for some (especially older mental patients who had spent many years institutionalized), it didn't work at all well for younger psychotics.

The results were apparent with vast numbers of homeless mentally ill people living on the streets, starting in the 1970s in California (where Lanterman-Petris-Short Act unintentionally caused this), and then the rest of the country as other states decided to follow California's mistake.

Also, increasingly stringent due process requirements concerning institutionalization in the 1960s and 1970s made it increasingly difficult for states to use the older model of locking up anyone that was crazy, even if they weren't an immediate danger to themselves or others.
4.30.2007 4:01pm
Clayton E. Cramer (mail) (www):

I strongly suspect that many of the white people who were formerly institutionalized now take drugs that control their mental problems.
Actually, many of the people (white and black) that used to be institutionalized aren't anymore because:

1. Much of the mental hospital institutionalization until Medicare came along, were poor, senile elderly. Medicare caused a mass transfer of these patients to private nursing facilities.

2. Typically 10-20% of mental hospital admissions before the 1950s were syphilitic insanity. As penicillin came into use, the number of new syphilis cases declined, and while it took a decade or two, eventually the syphilitic insanity cases that were such a large part of the mental hospital caseload died off.
4.30.2007 4:06pm
K:
Zubon and others correctly point out that the demographic of those in mental hospitals a half century ago is nothing like that of those imprisoned today. I believe it is so different that any attempt to link them is meaningless.

We must also consider the effect of the legal system itself on confinement statistics.

Every prisoner is there not only because a crime was committed but also because a judge afterward sent him to prision. If judges, because of statutes or discretion, sentence all of the guilty to prison then there obviously will be more prisioners. And yet there would have been no increase in crime.

And if probabation were always granted there would be no prisoners but the crime level would not have fallen.

Thus the legal system affects some statistics just as much as the actual level of crime or mental illness.
4.30.2007 4:14pm
Clayton E. Cramer (mail) (www):

Zubon and others correctly point out that the demographic of those in mental hospitals a half century ago is nothing like that of those imprisoned today. I believe it is so different that any attempt to link them is meaningless.
Here's a thought: maybe the demographics don't matter because those who commit murder have different demographics now?
4.30.2007 4:18pm
Scot Echols (mail):
Eric Rasmusen above has very effectively critiqued the science in this article. A couple of additional points I would like to add are as follows: First, that this same period saw a massive influx of American women into the workforce. The degree to which that displaced male workers is probably irregular, but may have contributed to the increase in out-of-work young men committing crimes. Second, in the period of decline, we were going through a philosophical phase of striving to use prison to rehabilitate people rather than as punishment. We have seen the backlash of this over the past couple of decades in sentencing increases, especially those driven by public initiatives. How have increases in sentences affected prison populations? I suspect strongly. Furthermore, the mentally ill commit crimes no more frequently, and usually much less frequently, than their non-mentally ill counterparts. Youth and maleness continue to be the prime indicators of violence. It is very interesting that the data shows that we exchanged a few hundred thousand neurotic, middle-aged, women who were institutionalized in an age when we did not have effective medications for anxiety, depression, or mild bipolarity (and thoroughly ineffective meds for psychosis)for about a million young men in prisons. I too have seen the numbers on prison inmates with mental diagnoses, but do you realize that the vast majority of these are ADHD and Antisocial Personality Disorder (aka psychopath)? Any mass murder is, by definition, a psychopath. Most individuals who commit crimes against other persons also meet the criteria. Why? Because committing acts without regard for other's lives and property is the definition of a psychopath. They have no remorse; that is what makes them a psychopath in the first place. They are also not considered treatable by most of the mental health community, so the whole idea of rehabilitating them is questionable.

Another consideration with hospitalization is that long-term hospitalization has not been shown scientifically to improve people's outcomes; in fact, quite the opposite. Someone above mentioned that schizophrenics do not benefit from the love and comfort of family. I could not disagree more. In fact, the Consumer Movement in mental health is opening the doors to people once considered capable of nothing but institutionalization to recover, some fully, reenter society, hold down jobs and relationships, and generally lead very meaningful lives. The current wave of fear-mongering about violence among the mentally ill is completely misplaced. The whole system does need an overhaul, but what it needs more than anything is for well intentioned, but misinformed, policy-makers to let evidence and outcomes drive mental health treatment and policy, not sensationalism.

Mental health consumers need more choices, not more restrictions. They also need the public to quit panicking every time a mentally ill person commits a crime. We used to do that every time a white woman accused a black man of rape. The result was widespread lynch-mobs, and it took a century to recover from that abomination. Let's hope it doesn't take that long with mental health.
4.30.2007 4:53pm
Bud Norton (mail) (www):
Houston Lawyer's comment about the man who wouldn't take his meds raises a point that should be kept in mind by those who advocate "treatment" as the answer to the dangerous mentally ill: so far, no one has yet invented a medication that makes people take their medication. Until that occurs, some sort of involuntary institutionalization has to exist for the sake of the public safety.
4.30.2007 5:05pm
Clayton E. Cramer (mail) (www):

Eric Rasmusen above has very effectively critiqued the science in this article. A couple of additional points I would like to add are as follows: First, that this same period saw a massive influx of American women into the workforce. The degree to which that displaced male workers is probably irregular, but may have contributed to the increase in out-of-work young men committing crimes.
Problem: women were working at higher rates in the 1930s than the 1950s. So why don't so those problems appear in the 1930s?


Furthermore, the mentally ill commit crimes no more frequently, and usually much less frequently, than their non-mentally ill counterparts.
All the actual studies (as opposed to "this makes me feel good to think it") say otherwise, with mentally ill committing violent crimes at substantially higher rates than the general population. This is not surprising; paranoid schizophrenics are suffering from often quite severe delusions that make them inclined to respond with violence. See here and here.


It is very interesting that the data shows that we exchanged a few hundred thousand neurotic, middle-aged, women who were institutionalized in an age when we did not have effective medications for anxiety, depression, or mild bipolarity (and thoroughly ineffective meds for psychosis)for about a million young men in prisons.
Wrong again. Yes, there were a lot of people hospitalized that might not qualify as psychotic. But there were lots of syphilitic insane people locked up as well.


Another consideration with hospitalization is that long-term hospitalization has not been shown scientifically to improve people's outcomes; in fact, quite the opposite.
You are correct that long-term hospitalization has a poor track record on curing schizophrenics. At best, it makes some what manageable--enough so to take their antipsychotic medications. This is not a spectacular state for them to be in, but it is safer than having them wandering the streets, dying of exposure or pneumonia--or, for some, committing murder.

Someone above mentioned that schizophrenics do not benefit from the love and comfort of family. I could not disagree more.
You can disagree all you want, you are simply wrong. Paranoid schizophrenia is a severe psychosis in which neurotransmitters are malfunctioning, resulting in defective sensory inputs--leading to quite severe, sometimes dangerous delusions. In many cases, paranoid schizophrenics misinterpret care and concern as attempts to cause them injury. My older brother is relatively typical of male paranoid schizophrenics. Your ignorance is quite astonishing.


In fact, the Consumer Movement in mental health is opening the doors to people once considered capable of nothing but institutionalization to recover, some fully, reenter society, hold down jobs and relationships, and generally lead very meaningful lives.
There are people with psychological problems for whom this is true. Paranoid schizophrenia is not depression, or bipolar disorder. About 30% of schizophrenics successfully recover; the remainder are not so fortunate.

The current wave of fear-mongering about violence among the mentally ill is completely misplaced.
No, it reflects reality--schizophrenics have high rates of violence compared to the general population.

Mental health consumers need more choices, not more restrictions.
This is part of what caused the disaster of the 1970s--this misplaced belief that psychotics were capable of being rational consumers of mental health services.
They also need the public to quit panicking every time a mentally ill person commits a crime. We used to do that every time a white woman accused a black man of rape. The result was widespread lynch-mobs, and it took a century to recover from that abomination. Let's hope it doesn't take that long with mental health.
The problem with your argument is that it is fundamentally wrong. The mentally ill do have higher rates of violence. That's one of the reasons that traditionally they were locked up--sometimes locked up without enough attention to the individual problems of the person.
4.30.2007 5:11pm
Shannon Love (mail) (www):
I would offer some cautions on interpreting historical mental health data.

The definition of mental illness changes over time. For example, the developmentally impaired and epileptics where once lumped with the insane but now are not. Most mental illness have no objective clinical findings (like a blood test) so the diagnoses are subject to periodic fads. The types of illnesses that must be dealt with have changed. Prior to 1945 and the widespread use of antibiotics, tertiary neurosyphilis caused much of the mental illness.

I don't buy the idea that we are imprisoning the mentally ill. Prison populations track by ethnic group and their is little evidence that mental illness does as well.

The reason we no longer have the infrastructure we once did is two fold (1) we either don't have the diseases we did in the past or we can treat them more easily. (2) Unless a mentally ill person has enough awareness to manage their own illness or they deteriorate to the point that they present an unambiguous danger, the system has no legal authority to treat them. It does not matter how many resources we devote to mental health if we can't actually get those resources to the patients.

That's the real problem.
4.30.2007 5:15pm
ras (mail):
FWIW (and I am just a layman), Herv Cleckley wrote a seminal work on psychopathology (free download for those interested) back when he was one of the very few to note its prevalence, and IIRC, a persistent theme was that:

1. Psychopath commits crime

2. Psychopath gets himself committed rather than incarcerated (not too difficult since their motivation is often unfathomable to the rest of society so "he must be insane")

3. Psychopath is observed during commitment to be obviously not insane and so is released.

The above, if it is to be addressed, often leads one down the contentious "insane but guilty anyway" path for those advocating more involuntary commitment.

One can do a brain scan that measures one's response to emotional words ("mother," "love," "rape") vs non-emotional ones ("table," " road"). Currently, it appears that non-psychopaths have an emotional reaction to the first group, whereas psychopaths process them more matter-of-factly, as if doing an algebra problem.

Solely for sake of arg, let's say that this measure (and if not this one, then some other) is accepted as definitive for psychopathology. Do we then preemptively lock up the psychopaths in prison forever? Do we incarcerate them permanently for their first serious offence since they cannot be rehab'd and generally reoffend regardless of punishment? Or do we treat their antisocial personality disorder (the new term for psychopathology) as a medical condition and put them into involuntary treatment forever?
4.30.2007 5:16pm
Clayton E. Cramer (mail) (www):

Houston Lawyer's comment about the man who wouldn't take his meds raises a point that should be kept in mind by those who advocate "treatment" as the answer to the dangerous mentally ill: so far, no one has yet invented a medication that makes people take their medication. Until that occurs, some sort of involuntary institutionalization has to exist for the sake of the public safety.
There are several problems:

1. A number of the antipsychotic medications have unpleasant side effects. That has been the reason that my brother has often resisted taking them.

2. Even when a patient reaches a point of sufficient stability to go out and reintegrate into the society, it is surprisingly easy to decide, "I don't need this anymore," or "I don't like the side effects--I'll just skip this for a while."

My brother was hospitalized for about six weeks in 1980 after an incident where he took a shovel to my mother. Unlike many of the other hospitalizations that failed, his doctor at the time was a psychiatrist named Harvey Ross who used a somewhat unorthodox technique called orthomolecular therapy--essentially, cutting him off from caffeine, sugar, and using high doses of niacin along with more traditional antipsychotic medicines.

When my brother came out of the hospital, he was "normal" for the first time since 1973. He went out and got a job, first at Carl's Jr., then working at the Marine base as an electronics technician (which was what he did before his schizophrenic breakdown). Had I not known of his past, I would have thought he was simply a very shy person. For a year or so, my brother was back, a normal part of our family, and not dangerous.

But somewhere along the way, he got into the habit of drinking coffee. His behavior at work started to decline, and they let him go. He has never recovered. His violent behavior came back, but slowly disappeared about ten years ago. He is not well--but he is at least no longer be arrested regularly for attacking strangers.
4.30.2007 5:19pm
Clayton E. Cramer (mail) (www):

I would offer some cautions on interpreting historical mental health data.

The definition of mental illness changes over time. For example, the developmentally impaired and epileptics where once lumped with the insane but now are not.
In the 19th century, yes. But by the time this dataset starts, there's a clear definition of retardation and epilepsy, and epileptics weren't involuntarily hospitalized. The retarded often were, or were hospitalized at the request of the family.


Most mental illness have no objective clinical findings (like a blood test) so the diagnoses are subject to periodic fads.
I agree, but over the period from the 1930s to the present, psychosis was pretty clear.
The types of illnesses that must be dealt with have changed. Prior to 1945 and the widespread use of antibiotics, tertiary neurosyphilis caused much of the mental illness.
About 10-20% of admissions, but a somewhat lower rate of those institutionalized, because syphilitic insanity had a short life expectancy compared to psychoses.

I don't buy the idea that we are imprisoning the mentally ill. Prison populations track by ethnic group and their is little evidence that mental illness does as well.
We know that about 6-15% of the prison and jail population is mentally ill based on a number of surveys done over the last 15 years. We are imprisoning mentally ill people. In many cases, mentally ill offenders are found to be legally sane and sent to prison.

The reason we no longer have the infrastructure we once did is two fold (1) we either don't have the diseases we did in the past or we can treat them more easily.
This is true with respect to syphilitic insanity and there has been a substantial transfer of senile elderly from mental hospital to private nursing care. But large numbers of psychotics that used to be hospitalized aren't anymore. I am old enough to remember when obviously crazy people did not sleep on park benches and camp out in the post office lobby at night.

(2) Unless a mentally ill person has enough awareness to manage their own illness or they deteriorate to the point that they present an unambiguous danger, the system has no legal authority to treat them. It does not matter how many resources we devote to mental health if we can't actually get those resources to the patients.

That's the real problem.
That is one of the problems: a combination of a nice little fantasy about community mental health treatment and increasingly strict requirements for commitment.
4.30.2007 5:27pm
Clayton E. Cramer (mail) (www):

1. Psychopath commits crime

2. Psychopath gets himself committed rather than incarcerated (not too difficult since their motivation is often unfathomable to the rest of society so "he must be insane")

3. Psychopath is observed during commitment to be obviously not insane and so is released.

The above, if it is to be addressed, often leads one down the contentious "insane but guilty anyway" path for those advocating more involuntary commitment.
California passed the Mentally Disordered Offenders Act in 1985 to deal with the problem of people who are legally sane but clearly dangerous after they complete their sentence. The involuntary commitment procedure is similar, but not identical to Lanterman-Petris-Short Act provisions for those found incompetent to stand trial for serious violent felonies. Some other states have similar provisions.
4.30.2007 5:36pm
ras (mail):
Clayton,

FYI, given your background w/your brother and your book-writing efforts, you might be interested in the work of Abram Hoffer who advocates the same therapy. Also, IIRC since I've read some of Hoffer's books but it was a while ago, I believe he noted that once on B3 a patient must continue to use it, and if the patient stops, then when he returns to it, the required dosage will be higher.

BTW, and just as an aside, Hoffer also recommends B3 for ADD, noting that ADD's symptoms are like a lesser manifestation of pellagra.
4.30.2007 5:41pm
Clayton E. Cramer (mail) (www):

FYI, given your background w/your brother and your book-writing efforts, you might be interested in the work of Abram Hoffer who advocates the same therapy.
Yes, Dr. Ross was following Hoffer and Osmond's strategy. It does not surprise me that it worked for my brother (at least until his resumption of coffee got in the way). Hoffer and Osmond have a plausible theoretical model that explains schizophrenia in terms of the epinephrine/adrenolutin/adrenochrome metabolism sequence. Niacin also works for at least some people as an antidepressant (it certainly helps me, along with assisting Lipitor in keeping cholesterol in check). Hoffer and Osmond's work in Saskatechewan suggests that these treatments work most effectively in the first year after schizophrenic breakdown, with much lesser effectiveness thereafter, perhaps because the brain adjusts to the impaired brain chemistry.
4.30.2007 6:59pm
tioedong (mail) (www):
The simple schizophrenics end up as street people, unless their familes keep an eye on them.
But the saddest are the mildly retarded, who literally don't understand right from wrong, and who often have brain damage related "explosive disorder" i.e. short tempers with violent outbursts.
When placed in jail, they end up raped and mistreated badly. When I worked in Pennsylvania, they were discussing a prison for long term care of the retarded criminals.
Ironically, those more retarded often do well in community group homes.
4.30.2007 7:01pm
Clayton E. Cramer (mail) (www):

The simple schizophrenics end up as street people, unless their familes keep an eye on them.
According to ICD-10, simple schizophrenia is actually pretty rare. The term "hebephrenic schizophrenia" seems to have replaced "simple schizophrenia" to describe schizophrenics who either have few hallucinations, or so few that they retain their grasp on reality. I had a girlfriend, long, long ago, with hebephrenic schizophrenia. She had hallucinations, but she knew that they weren't real. But over time, they would wear her down. The voices telling her "kill yourself" went on for a couple of days, and they were shouting so loud that she couldn't sleep, and she checked herself into a mental hospital. Perhaps the only good thing about deinstitutionalization was that space was readily available in California mental hospitals. (This was about 1978 or so.) She showed up at a mental health clinic, and within an hour, she was on her way to a state mental hospital.

But the saddest are the mildly retarded, who literally don't understand right from wrong, and who often have brain damage related "explosive disorder" i.e. short tempers with violent outbursts.
When placed in jail, they end up raped and mistreated badly. When I worked in Pennsylvania, they were discussing a prison for long term care of the retarded criminals.
Ironically, those more retarded often do well in community group homes.
There's a bit of case law on how to deal with them--and I'm not terribly impressed with the results. See Jackson v. Indiana (1972), in which a retarded man was charged with robbery, but lacked the capacity to understand the charges against him (he was also deaf-mute). He couldn't be sent to prison for his crime--not could he be held indefinitely waiting to become competent, since that wasn't going to ever happen. The Supreme Court basically told Indiana to release him--even though he was obviously a danger to others.
4.30.2007 7:10pm
Prospero (mail):
It is clear to me that involuntary institutionalization is a necessary thing. I have a brother in law that is bipolar and sometimes quite destructive and frightening. We cannot institutionalize him unless he threatens us or himself with specifics regarding a plan. The joke is that only he can institutionalize himself, which the paranoia of his disease prevents. When picked up by the police he "presents well" in the police station and is released in a few hours, only to come back to terrorize his family. Misguided compassion for the mentally ill ends up being oppression for the mentally well. Plus, you get the occasional GATech slaughters. This must change.
4.30.2007 7:46pm
Eliza (mail):
Why have the Georgia Tech murders got everyone so wound up about the mentally ill--has it been alleged that Cho had a mental disease? If so, which one? Was he hallucinating? Delusional?

I've had my fair share of mentally ill clients, and from what I can tell substance abuse is a better predictor of violence than mental illness. I wonder, is a violent criminal more likely to be a delusional psychotic or an intoxicated addict? Ordinary people are capable of incredibly vile things when they are high on crack, but I don't support locking them up on that basis.

There are lots of potentially dangerous people in the world. At some point people are simply going to have to accept that.
4.30.2007 8:50pm
michael (mail) (www):
Thanks for the link to the commitment papers.

The 'Mental Status Exam' looks like a prototype for a SNL skit. 'Doesn't acknowledge thought disorder.' Commentaries on Cho have repeatedly noted his 'rambling compositions.' This would have a characterization, depending on further specifics, as a type of thought disorder. No expert in psychiatry says it is self recognized; this for the simplest of reasons: It isn't. More generally 'thought disorder' includes delusional thinking. By definition a delusion is a bizarre belief that is not recognized as such; so this is like saying, 'He doesn't find himself delusional;' well, like who does? Etc.
4.30.2007 8:58pm
agesilaus:
I worked summers in between school terms at a State Mental Hospital in Florida. What I saw there was that the staff at the Hospital did their very best to turn patients back to society. But they recognized that some people refused to or were unable take responsibility for their own lives. Paternalistic? Probably but accurate none the less.

So these long term patients had three meals a day, were provided with all sorts of recreational opportunities in the hosital protected environment. They were offered jobs on site. They had good medical care and they were monitored to see that they actually took the medicines prescibed for them.

When the revolution came these people were thrown onto the streets and you still see them today, sleeping under overpasses and begging on the street. They bring a flood of petty crime to cities. They refuse to take medication, has minimal medical care, and no guarantee of three meals a day.

A few of them probably are the cause of more serious felonious crimes. They encourage the drug trade by being customers. And they generally make city life less safe and pleasant for everyone else.

Did society make the right decision in this case? I don't think that we did. The result has been much worse for the homeless and worse for society in general.
4.30.2007 9:23pm
Clayton E. Cramer (mail) (www):
Eliza writes:

Why have the Georgia Tech murders got everyone so wound up about the mentally ill--has it been alleged that Cho had a mental disease? If so, which one? Was he hallucinating? Delusional?

There wasn't a very detailed diagnosis when he was hospitalized, but there enough evidence to suggest paranoid schizophrenia--especially his "goodbye cruel world" video he sent to NBC.

I've had my fair share of mentally ill clients, and from what I can tell substance abuse is a better predictor of violence than mental illness. I wonder, is a violent criminal more likely to be a delusional psychotic or an intoxicated addict? Ordinary people are capable of incredibly vile things when they are high on crack, but I don't support locking them up on that basis.
There's sizable overlap between substance abuse and mental illness. The preferred expression is "self-medication," and there is some truth to it. They don't feel good, they have voices telling them things, they used depressants like marijuana or alcohol to make the voices stop.

The traditional argument for criminalizing intoxicants (including alcohol, although we have never been very consistent on this) is that they do cause people to do irrational and evil things like murder, rape, child abuse, drunk driving, and industrial accidents.
5.1.2007 12:12am
Eliza (mail):

There's sizable overlap between substance abuse and mental illness.

Clearly many mentally ill people are also substance abusers, though most substance abusers aren't mentally ill. But that's not my point. There are many identifiable subgroups in our society who are prone to violent, even murderous behavior, and in a very predictable way. A rapist is much more likely to rape again than a schizophrenic is to attack someone even once. That's why the crimes of madmen catch our attention--crimes of repeat violent offenders are so drearily commonplace. None of the murderers I've ever met has been mentally ill. Typically they're just depraved assholes.

But here's the thing. No free society can accept the notion of prophylactic incarceration. That's a moral decision, not a utilitarian one. There is one very small concession we make to utilitarianism, and that's strictly limited to situations where the state has evidence that a person is right on the very cusp of seriously harming himself or somebody else. Even then, those detentions are very short, and are reviewed by a judge (with counsel present) after the first few days and then again every few weeks.

I bet most of the people here that are so hot to lock up the mentally ill would be repelled by the idea of rounding up and preventively incarcerating crackheads, recidivist rapists and child molesters. I think it's because the mentally ill don't seem fully human to us--they're "not on the same planet,"--so it's easy to argue they shouldn't have all the same rights we proper humans have. One fellow here wants to lock up his brother-in-law because he's "bipolar and sometimes quite destructive and frightening." Our consciences give us permission to do this because we tell ourselves "it's for their own good."

Principled people should suppress that impulse. Respecting innate human liberty isn't always the easiest or safest way to go, but it's the right way.
5.1.2007 2:44am
whit:
"No free society can accept the notion of prophylactic incarceration"

which we already do btw. see: "civil commitments" (for the mentally ill, sex offenders)
5.1.2007 1:49pm
Ryan Waxx (mail):
So let me get this straight: Back then, people of certain political persuasions told us that mental illness was a "myth". They did this for the purpose of getting people out of mental institutions.

Then, when we followed that advice, we discovered that at least some of those people who had been deemed a danger to society... actually were, and then when they committed crimes, we had the choice of locking them up in jail for those crimes, or locking them up nowhere(because the MH infrastructure was gone.

Now, the people of the same political persuasion assure us that mental illness is very real. They do this for the purpose of getting people out of jails.

It seems to me, that unethical social scientists, who will say anything (even mutually contradictory statements on weather mental illness "exists"), are the problem and the main impediment to instituting a rational policy towards those who do or are likely to commit crimes.
5.1.2007 1:53pm
Clayton E. Cramer (mail) (www):
Eliza writes:

A rapist is much more likely to rape again than a schizophrenic is to attack someone even once. That's why the crimes of madmen catch our attention--crimes of repeat violent offenders are so drearily commonplace.
Actually, the crimes of the insane are drearily commonplace. Most of the gun mass murders that have taken place in the U.S. since 1984 had a person who was either clearly psychotic, or exhibited symptoms that caused family, neighbors, or police to be concerned about the killer's mental health.


No free society can accept the notion of prophylactic incarceration. That's a moral decision, not a utilitarian one.
That's your moral decision, but I'm not sure that everyone agrees with you. Throughout most of American history, mentally ill people have been locked up primarily for their own benefit, and secondarily for the safety of the rest of the society. At times this willingness to do so has gone too far. We have, since the 1970s, gone too far the other direction.

There is one very small concession we make to utilitarianism, and that's strictly limited to situations where the state has evidence that a person is right on the very cusp of seriously harming himself or somebody else. Even then, those detentions are very short, and are reviewed by a judge (with counsel present) after the first few days and then again every few weeks.
Even in California that's not the state of the law. Cal. Welfare and Institutions Code 5250 specifies the conditions for involuntary commitment. California's Mentally Ill Dangerous Offenders Act of 1985 also provides for very long-term civil commitment of mentally ill but legally sane felons.


I bet most of the people here that are so hot to lock up the mentally ill would be repelled by the idea of rounding up and preventively incarcerating crackheads, recidivist rapists and child molesters.
Huh? I live in a state where a judge can give a convicted child molester life in prison--and I've seen cases upheld by the Idaho Supreme Court where two counts of child molestation got life plus fifteen years. Recidivist rapes going to prison for life? Fine with me. I'm not sure that they should get the chance to become recividist rapists, but I recognize that a lot of people in our society feel sorry for rapists, and don't think we should hurt their feelings by calling them depraved.

As for crackheads: if they are in the habit of beating people to death, yes, it is time to go inside and stay there.

I think it's because the mentally ill don't seem fully human to us--they're "not on the same planet,"--so it's easy to argue they shouldn't have all the same rights we proper humans have. One fellow here wants to lock up his brother-in-law because he's "bipolar and sometimes quite destructive and frightening." Our consciences give us permission to do this because we tell ourselves "it's for their own good."
My brother seems fully human to me. But I spent too many years looking for him living on the street, in flophouses, and visiting in mental hospitals where he was in for observation--and no real treatment was possible because your view of civil liberties meant that he had to kill someone, or darn close to it, before he could be locked up long enough for treatment.
5.1.2007 4:03pm
Clayton E. Cramer (mail) (www):
Ryan Waxx writes:

So let me get this straight: Back then, people of certain political persuasions told us that mental illness was a "myth". They did this for the purpose of getting people out of mental institutions.

Then, when we followed that advice, we discovered that at least some of those people who had been deemed a danger to society... actually were, and then when they committed crimes, we had the choice of locking them up in jail for those crimes, or locking them up nowhere(because the MH infrastructure was gone.

Now, the people of the same political persuasion assure us that mental illness is very real. They do this for the purpose of getting people out of jails.
They aren't all the same persuasion. The motivations for deinstitutionalization in the 1950s and early 1960s were a desire for more humane and effective treatment of the mentally ill, and a belief (based on some evidence) that the institutions were not particularly humane or effective at what they were supposed to do.

The civil liberties crowd that brought many of the suits in the late 1960 snd early 1970s were zealots in love with the ACLU's ahistorical understanding of the Bill of Rights.

The dramatic expansion of prison populations in the 1980s and 1990s were because conservatives finally got control (briefly) of the government again, and decided that something had to be done to make the streets safe again--and apparently didn't see the interaction with deinstitutionalization.
5.1.2007 4:07pm
Prospero (mail):
One of the influences that released the mentally ill from mental institutions, I believe, was the 1962 book by Ken Kesey, "One Flew Over the Cookoo's Nest", which was later made into an Oscar winning movie with Jack Nicholson playing an odd, eccentric, lovable, admirable rogue who was improperly put away. We all cheered at his leading the other lovable eccentrics out of the "prison" of the institution. And so, the mentally ill were "freed" by a caring society, in part as a response to this fiction.

You may recall that the real villain of the movie was the evil, dictatorial Nurse Ratched. We all cheered when the rebel hero, Nicholson, thwarted her and "freed" the inmates.

This has become the paradigm of mental illness now, it seems to me: the mentally ill are just different and eccentric who are oppressed and misunderstood, and those of us who are trying to protect ourselves from them are evil, dicatorial Nurse Racheds who are revealing ourselves to be latent fascists with a need to oppress those that are different and don't fit in.

So, the mentally ill are free to roam the streets and tyranize, terrify, hurt, and kill. I realize that many of the mentally ill are not a danger to others, and some are capable of taking care of themselves to at least a minimal extent. But, I think that many cannot take care of themselves, and some are a danger to themselves and others. Cho is a tragic example.

The real insanity is being displayed by a society that cannot provide safety for itself, it seems to me.
5.2.2007 6:00pm