E. Fuller Torrey on Mental Illness

DATE April 17, 2006 ACCOUNT NUMBER N/A
TIME 12:00 Noon-1:00 PM AUDIENCE N/A
NETWORK NPR
PROGRAM Fresh Air

Interview: Journalist Pete Earley talks about his struggles
getting treatment for his son who suffers from serious mental
illness
DAVE DAVIES, host:

This is FRESH AIR. I'm Dave Davies, senior writer for the Philadelphia Daily
News, sitting in for Terry Gross.

Pete Earley is a veteran journalist who's written three novels and seven
nonfiction books on subjects ranging from Cold War spy rings to life in
Leavenworth Prison. But Earley's latest book, "Crazy: A Father's Search
Through America's Mental Health Madness," is about his own desperate attempts
to help his son who suffers from serious mental illness. Earley concludes
that laws enacted to protect the mentally ill from abuse and confinement to
state hospitals have made it almost impossible to get treatment for those who
don't believe they're sick. In his investigation, Earley found that 300,000
mentally ill people are in prison. I spoke to Pete Earley last week.

Pete Earley, welcome to FRESH AIR. You took on the subject of the mentally
ill in America's prisons because of a very personal experience of your own son
Michael. How did his mental illness present itself?

Mr. PETE EARLEY (Author, "Crazy: A Father's Search Through America's Mental
Health Madness"): Well, Dave, he was a student in New York, and it's very
typical, I found out, that a lot of young people in their early 20s, this will
be when a mental illness first manifests itself. He was a student in New
York, and I got a call from his brother saying, `Gee, something's wrong with
Mike.' I drove up there, and I found him in a completely delusional state. I
convinced him to come with me, and we headed back to Washington, DC, where I
live, and I called ahead and had the hospital standing by on alert. And I
went through the doors thinking, `Wow! I'll get help. He'll be OK. We'll be
able to help him think more clearly.' And it turned out that was absolutely
wrong.

DAVIES: You said he was delusional. What was he experiencing?

Mr. EARLEY: Well, my son has been diagnosed in different ways. He's been
diagnosed as having bipolar disorder. Another set of psychiatrists thought he
might have schizoaffective disorder. And another said it may be early stages
of schizophrenia. Bipolar disorder is a mood disorder, and you see people
going to highs and lows very rapidly sometimes. Schizophrenia is a thought
disorder where you may see hallucinations, you may not know, as in my son's
case, when you're awake or when you're asleep. And schizoaffective is kind of
a link between which you can have both mood and thought disorders. My son was
doing what was called rapid cycling. He would go from being euphoric and
thinking he could do anything to bursting into tears and not being able to
explain why. So on this journey from New York to Washington, my son had had
an earlier episode, and I was trying desperately to get him to take his
antipsychotic medication. He was convinced they were poison, and he would not
touch them.

DAVIES: What kind of conversation did you have on that long drive?

Mr. EARLEY: Well, at one point, my son said to me, `You know, no one dies
unless they want to.' And I said, `Well, did my wife's first husband die
because he wanted to?' And then he'd be real quiet. And then his mind was
just jumping from one subject to another. He would see a bumper sticker, and
he'd laugh because it had some kind of secret message, and he'd say, `God,
dog. God dog. Get it?' Meaning it could be reversed. He would be laughing
one minute, talking about sex, rock and roll, rap music, and the next minute,
he'd start sobbing uncontrollably, telling me that he'd committed some
horrible sin that he couldn't tell me about. It was just really
heart-wrenching.

DAVIES: I can only imagine what that must have been like for a father to see
your son in that kind of pain and disorientation. You end up at an emergency
room and have a very frustrating encounter with a physician there.

Mr. EARLEY: Well, you know, we're trained to believe--we grow up believing
that if we take someone who's ill, we get them into an emergency room, they
can get help. And so, yes, it was horrible riding with him, but I clung to
this hope that as soon as I got him in the emergency room, the doctors would
know what to do. We got to the emergency room, and, of course, the nurse was
rolling her eyes when she saw what kind of condition he was in, and we went
into a little holding area. They isolated us from everyone else. And we
proceeded to sit there. And an hour went by, and my son was reading an old
New Yorker, and he just kept studying one page because God was sending him
secret messages on this page. Another hour went by. A third hour went by,
and after four hours of waiting, my son said, `Well, I'm leaving.' And I said,
`Wait, wait, wait.' And I dashed out in the hall, and I flagged down a nurse,
and I said, `Please, my son is psychotic. We've been here four hours. Send
someone in.' And the doctor came in, and it was amazing to me because he came
in, and he had his hands up as if he was going to surrender, and he said,
`Look. I'm going to tell you right now there's nothing I can really do for
your son.' And I thought, you haven't even examined him. How can you say
that? And I said, `Well, he's been diagnosed with bipolar disorder. He's off
his medications. He has a history.' And he said, `Up to this moment, none of
that matters.' And I was shocked. And I said, `What do you mean it doesn't
matter? Would you say that to someone who, you know, has had a heart attack?
To say that to someone who has cancer?' And he said, `No, it doesn't matter.
All that matters is what he is thinking right now.' And he turned to my son,
and he said, `Can you count backwards from seven?' And my son started to count
backwards. And he said, `OK, what does the phrase "Don't cry over spilt milk"
mean?' And my son explained it to him. And he said, `If I ask you to take
your medicine, will you take it?' And he says, `Absolutely not. That's
poison.' He says, `Well, do you know who I am?' And my son says, `Yes. You're
the witch doctor. Oh, e, ooh, ah, ah.' And they both kind of laughed. And
the doctor said, `Are you planning on hurting yourself?' And I interrupted,
and I said. `He talked about killing himself on the way down here. He asked
me, he said, "Dad, what would you think if someone you loved killed
themself?"' And the doctor immediately turned to my son and he said, `Are you
thinking about killing yourself?' And my son said, `Absolutely not.' He said.
`Are you thinking about killing someone else?' And he said, `No.' He said,
`OK. The law says you have to be an imminent danger to yourself or others.
He's not, so there's nothing I can do.' And my son said, `Can I go?' And he
said, `Yes. Absolutely.'

Now I'm talking to the doctor trying to understand why he refuses to treat my
son, my son steps out, he gets into a loud argument, they call security, and
I'm thinking, `Now, look. He can't even get out of the emergency room without
getting into some kind of trouble. Surely, you'll see to help him.' And they
said, `No. You need to take him home or he'll be arrested.' So I took him
home.

Dave, I cannot really explain to you how horrible it is to watch your child
decompensate over the next 24, 48 hours, to watch their mind go deeper and
deeper into this abyss and not be able to do anything about it. It is the
worst feeling for a parent.

DAVIES: I know that there came a point at which he ended up at the home of
your ex-wife, and you said that he picked up a videotape of an Oliver Stone
movie which he was convinced held secret coded messages for him. It became so
frustrating that at one point you ended up lying to a psychiatric social
worker and saying that he'd threatened you. What led to that?

Mr. EARLEY: Absolutely. What happened was during this period when he's with
me in my house, I am so desperate that I actually take medication, old
medication that he had, and I'd smash it up and try to hide it in his cereal.
And he sees it, and he becomes outraged, and so he demands to be taken to my
ex-wife's house. The next day, he gets up early in the morning, and he goes
out and walks into a Starbucks and announces that he can pick up a bottle of
water and drop it and nothing will happen. And, of course, he drops it and it
breaks. He runs out the store. The clerk who recognized him, happened to
have gone to high school with him, calls the police. So they know that they
have someone who's delusional who's in the area. Then they get a burglar
alarm call. What he had done is he had felt completely dirty, he felt
ashamed, so he picked up a patio chair at a stranger's house and threw it
through the back patio window, gone in the house, he'd turned over the
pictures of the children on the mantle, he'd gotten himself some liquor out of
the cabinet, and then he'd gone upstairs and drawn a bubble bath. Thankfully
the people weren't there. The police arrive.

A couple days before, a psychotic person in Maryland had killed two officers,
so the police in Fairfax County were worried about going in this house. They
turned the dog loose. It went in and grabbed my son in the arm, locked its
jaws on him, pulled him down. It still took six officers wrestling with him
to get him out. Thankfully, they did not hurt him. He thought because he had
a high sense of paranoia, he told me later that he thought they were trying to
kill him. And they took him to a holding center. When I arrived there--the
police called, I arrived there--actually a policeman was out front, and he
said, `Mr. Earley, even though your son has broken into a house, even though
your son is obviously not thinking clearly, he will not be allowed to stay at
the hospital unless you go in there and tell them he's threatened you or
someone else.' And I said, `You're kidding.' And he said, `I'm not kidding.
He'll be taken to jail. You don't want him in jail.' So I went into the
holding center and told the psychiatric nurse there, I said, `He's threatened
to kill me. I need to have him locked up.' And she said, `Will you sign a
statement saying that?' I said, `Absolutely.' And immediately then, he was
taken to a hospital where he was held for 72 hours.

DAVIES: So it took a lie to get him treatment?

Mr. EARLEY: Not only did it take a lie to get him into treatment, but when I
got to the hospital, and I said, `Finally, we're going to get him help,' they
said, `Oh, no, no, no, no, no, no. Just because he's here doesn't mean that
we're going to give him medication. He has the right, even though he is
clearly psychotic, to refuse to take any medication and not take any
treatment.' Then I get a phone call, and, of course, you know, I've been a
journalist for 30 years. I thought I understood how the system works. And
what I found out was I didn't know anything.

I get a phone call from a public defender, and because of so many stories I've
done, I've kind of always looked at public defenders as kind of the good guys
who are battling, you know, to make sure one's rights are protected. And
that, in fact, was what this person was doing. And I said, `Oh, good. You're
going to call. You've called. You can help me get my son help because he
needs treatment.' And she said, `No, no, no, no, no. My role is to defend his
rights, and if he wants to be released immediately, that's what I'm going to
go do.' And I said, `He's psychotic. He's not thinking clearly. This is my
son. I love him. This isn't a case of some elderly woman who we're trying to
put in a state mental hospital and take all her money.' And she said, `This is
the law. I'm here to protect your son. Even if he's psychotic, if he wants
out, I'll get him out.'

Fortunately, at the hearing the next day, my son, I'd met with him and
persuaded him that he needed to stay in the hospital. So my son agreed to
stay. That night, the doctor called and said they'd found some of the
medicine on the floor, that he had cheeked it. He had put it in his mouth and
then spit it out. So we didn't really know if he was going to end up taking
his medication or not. I went to see him again, and I talked to him. And it
happened to be my birthday. And we had a very--as you can imagine, I was in
tears, he was in tears. And he told me, he said, `I don't know if I'm awake
or dreaming. Is any of this really happening?' And I said, `It is happening,'
and I showed him the wounds on his arm where the dog had bitten him. And he
goes, `I keep thinking I'm just going to wake up. This is a dream. I'm going
to wake up. I'll be in my bed. I'll be back in school.' And I said, `It's
not. You have to take your medicine. Please, please take your medicine.'

So he began taking his medicine, and I thought, `Wow, we've crossed this hump.
You know, I can get my son back.' And three days later, I got a call from the
psychiatrist at the hospital, a very wonderful man, who said, `The insurance
company is insisting your son be released. He is not imminent danger to
himself or others. The law says he has to be kept in the least restrictive
possible circumstances. And he's taking medication.' And I said, `What do you
think?' And he said, `I think as soon as we turn him loose, he'll quit taking
medication, and he'll disappear. And there's a good chance you'll lose your
son.'

DAVIES: What happened as you confronted this insurance company representative
about the issue?

Mr. EARLEY: What happened with the insurance was the doctor
said--recommended, `If it's all possible, keep your son here. We need more
time with him.' And I called the insurance company, and the person was very
polite, but very firm and said, `We will not continue to pay your son's bill.'
And at that point, I committed another ethical violation. Not only did I--had
I lied to get him in, but I told them, I said, `Look. I'm a former Washington
Post reporter, and I happen to know Mike Wallace at "60 Minutes." And I will
call The Washington Post, I will call Mike Wallace. I will do anything I can
to call attention to you turning my son loose.' And within an hour--and of
course, that's a journalistic violation. Journalists are not supposed to use
their role in that kind of way for personal gain. And I would--I knew that,
but I felt so desperate about my son. And within an hour, the insurance
company had backed off.

And that night, the hospital released a young girl who's very similar to my
son's age. Her parents and I had met in the waiting room. And that girl left
the hospital and disappeared. And to this day, those poor parents have no
idea where their daughter is. So I felt, you know, some vindication in
violating my ethics.

DAVIES: Writer Peter Earley. We'll talk more after a break. This is FRESH
AIR.

(Announcements)

DAVIES: If you're just joining me, we're speaking with Pete Earley. He's a
veteran journalist who describes the painful story of his son's mental illness
and his own research into our mental health system. The book is called
"Crazy: A Father's Search Through America's Mental Health Madness."

Now you told us earlier that your son when he was in a delusional state had
broken into an unoccupied house and, you know, vandalized it a bit and run a
bubble bath and had broken some things. After he got some treatment, he had
to go to court and face the consequences of that break-in.

Mr. EARLEY: That's absolutely correct. I was shocked that he was charged
with two felony--serious felony crimes. And my son at the time was in school
studying for a career that requires a state license. And if you had felonies,
you could not get that. And, of course, as the father, I was totally
outraged, saying, `This is wrong. Why would you charge him with two crimes
when he clearly was delusional?' I was so frustrated, I couldn't sleep at
night and my wife said, `Look, you're a journalist. Why don't you investigate
this?' And then I discovered that jails and prisons had really become our new
asylums, that there were 300,000 people in jail today with serious, severe
mental illnesses. There's 500,000 of them on probation. Sixteen percent of
everyone in the jail, 16 percent have a mental illness. And I wanted to know
why. I wanted to figure out why were we jailing people who were clearly
psychotic.

DAVIES: And as you took on this subject, I guess what you discovered was
that, you know, decades ago, those hundreds of thousands of people were in
state mental hospitals, right?

Mr. EARLEY: Absolutely. Dave, what happened was, you know, it's come full
circle. In the 1700s, the lunatics, as they were called, were all locked up
in jails and prisons, and Dorothea Dix came along in the 1800s and said,
`Look, these people need treatment. They don't need to be incarcerated.' And
so she literally, single-handedly, was responsible for building state
hospitals. And by the 1900s, the entire country had state hospitals. Well,
sadly, these things turned into really horrific places, as we all know. By
the 1940s, we had series like Bedlam in Life magazine, and the book, "Snake
Pit." We had exposes where they were comparing these hospitals to
concentration camps. And there were horrific things happening in them.
There's no doubt about that.

What happened in 1963 is Kennedy came along, and he said, `OK, let's build
community-based treatment centers.' And everybody went, `Yeah, that's the way
to go. Let's get them out of these state hospitals, get them out of these
warehouses.' But really not much happened. Then what happened was you had the
civil rights attorneys come along, and they started filing lawsuits against
these horrific places. At about that same time, you had the development of
new antipsychotic drugs. Thorazine appeared and, all of a sudden, it seemed
possible to actually treat people in the community.

So you had this combination of you had thorazine, you had civil rights suits
starting to come up in the '70s and the '80s, and you had more of a drive for
community-based. You also had what was called the anti-psychiatry movement
where people said, `Hey, who's to say what's normal, and people with mental
illnesses like schizophrenia they actually just have a different way of
thinking.' There was no conception that this was actually a chemical problem.
It was more of a choice. People choos--were choosing to be mentally ill, to
act this way.

All of those things came together, but the real key I discovered during my
research in deinstitutionalization was the federal government. All of a
sudden, the federal government said, `OK, we'll start giving these people
benefits. We'll give them various kind of federal benefits,' And then the
state legislators looked at it and said, `Hey, let's push them off onto the
feds.'

So what happened is you went from 500,000 people being in state hospitals,
overnight, to 100,000. And they started showing up in our streets. And then
they started showing up in our jails. And you can plot this out, you can see
how people moved. It's called transinstitutionalization. They move from the
state hospitals to the streets then into our jails.

DAVIES: In addition to this movement by the federal government and the state
legislators to move people out of these huge state hospitals and to community
treatment settings, you had a growth of lawyers in effect asserting the rights
of mentally ill people to refuse treatment and making it more and more
difficult for a relative or a loved one to commit someone to treatment.

Mr. EARLEY: That's absolutely right. What happened was you had the Mental
Health Bar, a group that later became the Bazelon Center here in Washington,
who in the '70s and '80s were looking at this saying, `You know, these
hospitals are so horrible. Let's do our best just to shut them down.' And the
way they did that was in the courts. And the key ruling in all of this, one
of the key rulings, well, the first one was the Supreme Court's decision that
you can't arrest someone just because they're mentally ill. The second key
ruling was that commitment procedures had to have the same kind of legal
protections as a criminal case. And so that took it out of the world of the
doctors and the parents and the loved ones and put it into the world of a
criminal-type trial.

So even if you have a situation where the judge and the defense attorney and
the person who's supposedly is trying to get this person into treatment,
oftentimes there's a prosecutor, even though all of them may agree that this
person is clearly psychotic and not thinking clearly, the law says they have
to be an imminent danger, and so the civil rights attorney will say, `I'm
sorry. I know the person is psychotic, but we got to turn him loose. That is
the law.'

DAVIES: Writer Pete Earley. His latest book is "Crazy: A Father's Search
Through America's Mental Health Madness." He'll be back in the second half of
the show.

I'm Dave Davies, and this is FRESH AIR.

(Announcements)

DAVIES: Coming up, we continue our interview with Pete Earley, author of
"Crazy: A Father's Search Through America's Mental Health Madness." And we
discuss ways to get treatment for those who don't believe they're sick with
psychiatrist E. Fuller Torrey.

(Announcements)

DAVIES: This is FRESH AIR. I'm Dave Davies, sitting in for Terry Gross.

We're speaking with journalist Pete Earley, whose latest book is "Crazy: A
Father's Search Through America's Mental Health Madness." It's in part the
story of his efforts to get his own son treated for his serious mental
illness. Earley came to believe that laws enacted to protect the mentally ill
from abuse and unnecessary confinement have made it practically impossible to
get treatment for someone like his son, who believed his medicine was poison
and refused treatment.

The current law essentially seems to require very dire circumstances before
someone can be forced into treatment, imminent danger to themself or others.
Is it clear in your own mind how you can craft criteria which work better, get
treatment they need--people treatment they need without trampling their
rights?

Mr. EARLEY: Well, I come at this as a parent, and so obviously--and I also
come as a journalist who's used to exposing wrong. I don't pretend to be the
overall expert on how you could craft a law, but I think there would be a way
to either reinterpret the imminent danger clause, remove the imminent part or
set up some kind of tribunal panel, mental health court, some way where you
had someone who was perhaps not the parent but a parent representative, a
judge, as well as a doctor. We can't just limit it to the law. That is cruel
when you're dealing with someone who is not thinking clearly, who believes
that everyone is out to get them, who believes their life as being threatened
by doctors, or, you know, their own parents. I'd never met anyone who has
been taken off the street who has been helped by medication. And remember,
medication, while it's not the answer, helps 70 percent of people with mental
illnesses, who has said, `Gee, I wish you would have left me there.'

DAVIES: Well, Pete Earley, we spoke earlier about your son's mental illness
and the terrible traumas that you went through trying to get him treatment,
and your book ends on a helpful note because in it you describe how he did get
his meds and he did get a whole lot better, and there's a wonderful lunch that
the two of you share in which, you know, he's talking about going back to
graduate school and looking at building his future, and yet--you're enjoying
it, and yet you note that the odds are that most people in his situation will
at some time go off their meds and suffer relapses. How is Mike doing?

Mr. EARLEY: Well, the book was finished more than a year ago. It takes that
long to get it printed. And I thought everything we'd been through after two
years of this, after all the therapy, after the court, surviving going through
the courts, after him being on probation, I thought,`Wow! We've learned a
lesson.' And what I discovered is mental illness is not a lesson to learn.
Within three months after my son went off--was off his probation, he stopped
taking his medication. That led to another harrowing six months where finally
we were able to get him back on.

And the reality is all of us who love someone who's struggling with mental
illness, there is no end. There is no happy ending. You are always dealing
with a very cruel disease that you have to be on guard about. And so it just
continues on and on. Now the biggest problem for me, to answer your question
is, as a parent trying to learn when to let go, trying not to look at my son
every day and say, `Is he on his meds? Is he off?' Trying not in interfere
with his life but to let him live his own life. And that's very tough when
you're dealing with someone who you know has an organic brain disease.

DAVIES: Well, Peter Earley, thanks so much for speaking with us, and
certainly wish you the best for you and your son and your family.

Mr. EARLEY: Thank you very much.

DAVIES: Writer Pete Earley. His latest book is "Crazy: A Father's Search
Through America's Mental Health Madness."

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Interview: Dr. E. Fuller Torrey of Treatment Advocacy Center
discusses outpatient treatment for mentally ill patients
DAVE DAVIES, host:

When Pete Earley's son became delusional and refused to take his antipsychotic
medication, Earley concluded that mental health laws were preventing him and
other parents from getting help for their children. The leading advocate for
changing commitment laws to make it easier for courts to compel treatment for
seriously disturbed patients is Dr. E. Fuller Torrey. He's a research
psychiatrist specializing in schizophrenia and manic-depressive illness who's
written 20 books on mental illness and its treatment. He's also president of
the Treatment Advocacy Center. I spoke to Dr. Torrey last week.

E. Fuller Torrey, welcome to FRESH AIR.

Dr. E. FULLER TORREY (President, Treatment Advocacy Center): Thank you.

DAVIES: Pete Earley in his book described a very troubling incident he had
with his son who was mentally ill, and it was an occasion relatively early in
his son's mental illness at which Pete Earley was driving his son back from
New York. He clearly seemed to be paranoid, delusional, and he was resisting
taking medications which seemed to help his mental illness. Pete Earley
finally gets him to an emergency room, and the doctor there asks him a few
basic questions of orientation, concludes that his son is not an imminent
danger to himself or anyone else and essentially tells Pete Earley `There's
nothing I can do. Your son doesn't want to take his medication. I can't
force him to be treated. I have to release him.' And so Pete Earley is left
in his fury and his son is left to go off and continue his mental illness.

It's a very troubling story to hear. What can a parent do in that situation
where they're in an emergency room, and the doctor says `If your loved one
doesn't need to be treated, there's nothing I can do'?

Dr. TORREY: Well, first let me say, Dave, that this is a very common
scenario. Pete Earley's experience with his son is one being experienced by
literally hundreds of thousands of families around the United States who have
family members with schizophrenia and bipolar disorder. In terms of what he
could do in that situation is the first thing he should do is to make sure
that he understands the laws of the state, in this case Virginia. Does the
state have what we call an outpatient commitment statute? Well, Virginia
does. It's difficult to use. But the bottom line is how do you get treatment
on to an individual with a brain disease like schizophrenia or bipolar
disorder? How do you get treatment when the person is not aware that they're
sick? When the person is completely resistant to taking mediation, even
though the medication is what's going to get them well on it? So number one,
you find out what the state laws are.

Secondly, you would--as Pete I think attempted to do, you would try and use
whatever leverage you have, both with your family member and also with the
treating psychiatrist in this case. And if I were in Pete Earley's situation
in that, I would say, `I will have my lawyer contact you in the morning. If
you release my son this afternoon and anything happens to him, I'm going to
hold you personally responsible, etc., etc., etc.' Those are all important
things.

And the third thing is what many of these families end up doing is using the
laws to get treatment. In other words, most people like Pete Earley's son end
up committing a crime, usually a misdemeanor crime. In his case, it was
breaking into somebody's home and taking a bath in the bath tub. But indeed
he did have charges against him. Many of the families then end up using that
as the way to get leverage to insist that their family member get into a
treatment system and the alternative is going to jail. And these now exist in
what we call mental health courts in many of the states, and they have grown
up again as a way to fulfill this huge vacuum that has evolved over the last
30 years as we've changed the laws to make it almost impossible to treat
people who need treatment but who themselves don't know that they need
treatment.

DAVIES: Now let me back up here. You said that a lot of states, including
Virginia, have an outpatient commitment statute. What does that provide for
in terms of compelling someone who needs psychiatric help to receive it?

Dr. TORREY: The way it works, Dave, and we have a District of Columbia also,
and when I was working for many years at St. Elizabeth's Hospital, I used it
many times. I would go to court with someone who had, say, been admitted 20
times, and I would say to the judge, `Your honor, this fellow's been in and
out of the hospital 20 times. He has no awareness of his illness. He needs
to stay on medication. I would like to release him this Thursday on condition
that he come back and get his injection every three weeks to stay on the
medication.' That's what's called an outpatient commitment. You're basically
saying to the individual, `Yes, you can live in the community on the condition
that you remain on your medication, and we have a way to monitor that you're
remaining on your medication.' Forty-two states have statutes like this.
Eight states do not. But even in those 42 states that have them, including
Virginia, it's often underutilized or, particularly in some states, it is so
difficult to use that many families don't use it.

DAVIES: It sounds, though, in a case like Pete Earley was confronted with,
where his son did not have a long history of hospitalizations but clearly was
behaving in an irrational, delusional way, but it doesn't sound as if that
outpatient commitment statute really would have applied to him.

Dr. TORREY: If he had had no dangerousness and certainly in Virginia I think
this is true, I think that's probably true. But this is because we have
changed the laws to make it very, very difficult to treat people who are
mentally ill even if they don't understand that they're mentally ill.

DAVIES: Dr. E. Fuller Torrey. He specializes in schizophrenia and manic
depressive illness. We'll hear more after a break.

This is FRESH AIR.

(Announcements)

DAVIES: Let's get back to our interview with psychiatrist E. Fuller Torrey.
He's president of the Treatment Advocacy Center.

Now you mentioned that a lot of people who are mentally ill will end up
committing a crime and thereby entering both the court system and the mental
health system that way. And you indicated that if they are arrested for a
misdemeanor, that often is an avenue by which a court can compel treatment
rather than incarceration.

Dr. TORREY: That's exactly right, and these often go under mental health
courts where these are special court set up by the state just to handle people
who are mentally ill. It is so difficult to get treatment that some of the
state officials will tell families, `You know, the best thing that could
happen to your son or daughter is to get arrested because then we would be
able to get them into a treatment program. But until they're arrested, we
can't do anything.' That's a really sad state of affairs when that's the
situation, and that's exactly the way it is.

DAVIES: Now if the arrest is for a felony--I mean, let's say you shove
someone or hit someone or something that's regarded as an assault, does that
disqualify you for this kind of outpatient treatment and instead relegate you
to a life of being in prison?

Dr. TORREY: Again, that varies by state. These are state laws, and in some
states, the mental health courts will indeed include felonies and in other
cases they will not. Clearly, if you have a felony charge against you, it's
considered much more serious. And often that person will end up in the state
prison system and then will be on parole when they are finally released, and
the parole will effectively keep them on medication as long as they're on
parole.

DAVIES: Do you think that going into the prison system as opposed to a
compulsory outpatient treatment plan can help people with schizophrenia or is
it almost always a bad thing?

Dr. TORREY: No. I've actually seen it be a good thing, and the fact that I
can say that I think is very sad. But going into the prison system in some
states is the only way now you can into involuntarily that you can get into a
treatment program. I think it's important to emphasize that about half the
people with the kind of illness that Peter Earley's son had, bipolar disorder
and schizophrenia, about half these people are not aware that they're sick.
They have damage to the part of the brain that we use to think about ourselves
and therefore they go into the category of people like Alzheimer's disease who
don't know that they're sick. But we haven't paid attention to that fact. We
just paid attention to civil liberties and saying nobody who doesn't want to
be treated should be treated. And that's why we have so many people with
mental illnesses in the jail and also among the homeless on the streets.

DAVIES: These outpatient commitment statutes are, of course, controversial.
Your adversary in this debate often is the Bazelon Center for Mental Health
Law which makes the case that these kinds of statutes represent really a
dangerous coercion of the mentally ill and a violation of their rights and
that what you really need is much more extensive funding for the kind of
treatment that will help and that once you indulge society's penchant for
locking people up, then you allow them to forget about it and you lose the
pressure for real funding and real treatment. What about that argument?

Dr. TORREY: Yes, it's very important to fund adequate services, but if you
don't think you're sick, you're not going to use services, no matter how
adequate they are or how attractive they are because there's no reason to.
Some of my patients from St. Elizabeth's are sitting a few blocks from here
over in Lafayette Park today, and they really think that they're in touch with
the president and they really think the CIA is beaming messages into their
heads. It's important to understand that they have no awareness of their
illness at all. In terms of locking people up, one of the nice things about
the outpatient commitment statutes is it doesn't lock anybody up. What it
does is say `You can live in the community as long as you stay on your
medication, and for that reason, we don't have to lock you up.'

And we know from the data from outpatient commitment statutes that outpatient
commitment accomplishes many things. It decreases rehospitalization markedly,
it decreases homelessness, it decreases the number of these people who end up
in jail, and it decreases the episodes of violence. So we know it works, and
we know it works by leaving people in the community. It's not necessary--in
most cases, it's not necessary to lock them up.

DAVIES: I guess a crucial distinction between that kind of treatment and the
typical community-based treatment is that you're not simply giving the patient
a bottle of pills which they are on their own to take. They must come in and
actually get regular injections of the antipsychotic drugs.

Dr. TORREY: There's several ways to do it, Dave. One is you can have them
come in and get their injection every two weeks, every three weeks, that works
very well for some. In some cases, you can do as they do for people who have
tuberculosis who refuse to take medicine and that is have them come to the
clinic each day and take their pills in front of a public health nurse or in
front of some kind of professional. In other cases, you can monitor their
urine. You can do random urine checks, and there are ways to do this to make
sure that they are taking the medication. So you can do it in a variety of
ways. But we haven't done it very well because we haven't used this very
much.

DAVIES: When a patient is committed by the court to one of these outpatient
treatment programs that you have described, they show up regularly and get
their medications under the supervision of a professional. How does the court
insure that the patient stays with the program?

Dr. TORREY: Well, I can tell you how it worked here in the District of
Columbia, when I was working at St. Elizabeth's Hospital and used it is once
I had the approval of the court for an outpatient commitment, I would say to
the individual, usually a male because they're much more inclined not to take
medication, I would say, `You need to come in every three weeks for your
injection. If you don't come in, I have the right to have a District of
Columbia policeman come to your house and bring you involuntarily to the
hospital where we can keep you in the hospital.' You almost never have to
actually do that, but the court does in--that's part of the outpatient
commitment is you report back to the court if the person doesn't come in and
the court can then approve a law enforcement officer going and bringing the
person to the hospital. The remarkable thing is that once they're on
outpatient commitment, it usually goes very smoothly. You almost never have
to involuntarily hospitalize them.

DAVIES: Of course, these are often lifetime illnesses, and people need to
remain on their meds for years and years. How long does the court supervision
last in a case like this?

Dr. TORREY: Court supervision will last for varying periods depending on the
jurisdiction, depending on the state. Six months is not unusual. In some
cases, it will go for as long as a year. I'm not aware of anywhere it goes
longer than a year on it. And in some states, it's only 90 days where you
have to go back to court and get it renewed on a regular basis on it. So once
the person is on it and doing well on it, then it often tends to just carry
itself and will be renewed, and remarkably, many of the people once they're on
it are quite happy to be on it because they're tired of being homeless,
they're tired of being in jail, and they're tired of being victimized as often
happens when you're severely mentally ill.

DAVIES: There are a lot of stories of people with severe mental illness,
schizophrenia, who once they are on their medications and stabilized, feel
much better, begin thinking rationally and then forget, you know, what it felt
like, you know, to be so tormented and conclude, `I'm fine. I really don't
need my medication.' And they may dislike side effects that the medications
have. What do you do--what happens in a situation like that where the court
has gotten them back on their meds and gotten stable,, but they conclude they
just don't need them?

Dr. TORREY: This is a very common story, and I think Pete Earley can talk
about this very articulately because that's what's happened to his son on
occasion on it. First I think we all would like to deny that we're sick.
Nobody would like to have an illness like schizophrenia or bipolar disorder.
These are lousy diseases on it. And when you're feeling better and on
medication, it's not uncommon to say, `Well, you know, I don't think I really
need this. Let me try it without it.' That happens all the time, and that's a
major problem. Secondly, you mentioned side effects. Side effects is a
problem.

As a treating psychiatrist, my job then is to find a better medication, by
being better, I mean still produces improvement in your symptoms but without
the side effects on it. And fortunately now we have really, oh, eight or 10
medications. For both schizophrenia and bipolar disorder, we have many more
choices than we had even 10 years ago. It doesn't mean that everyone responds
to these medications, but, oh, 80, 85 percent of people will respond more or
less on it. But this is an issue we have to deal with all the time with the
severely mentally ill because going off their medication is really a very,
very common phenomena.

DAVIES: And so what do you do then?

Dr. TORREY: What I do with my patients is I try and persuade them as best I
can. I try and remind them of all the terrible things that's happened when
they were homeless or in jail or involved in episodes of violence or being
victimized. I work with their families and with their significant others and
try and persuade them and remind them of what happens when people stop taking
their medication. This is a daily phenomena for I think all psychiatrists and
psychologists who have to work with people with severe mental illnesses. You
do everything you can to persuade them. Sometimes you can't persuade them.
Then you have to go to legal mechanisms like outpatient commitment.

DAVIES: And is part of the things you tell them, `Now, you don't want to go
back before the judge, do you?'

Dr. TORREY: Of course, and especially if they have misdemeanor charges
holding over their head, then the court still has leverage on them, and you
just say, `You know, if you don't stay on your medication, then the judge can
send you to jail.' That's pretty good leverage. And that's sometimes the only
leverage you have. So you use whatever persuasion, coercion, blackmail that
you can to try and keep people on the medicine to keep them well so that they
can lead a reasonably normal life.

DAVIES: Psychiatrist E. Fuller Torrey. We'll talk more after a break. This
is FRESH AIR.

(Announcements)

DAVIES: Let's get back to our interview with Dr. E. Fuller Torrey. He's a
psychiatrist and president of the Treatment Advocacy Center, which seeks
changes in the nation's mental health commitment laws.

Many of the hundreds of thousands of people who are mentally ill in
communities and on the street today, two or three generations ago would have
been in state hospitals, which were, you know, renown for abuses. Should we
have more state hospitals than we do? Or was it the right thing to close
them?

Dr. TORREY: Well, I would--first of all, let me say that 95 percent of the
people who would have been hospitalized 50 years ago are not hospitalized now.
Less then 5 percent of the people proportion to population are now in
equivalent of state hospitals. So it's a very, very small group. No, we need
a few more beds but most of the people living in the community can live in the
community, and in fact living in the community is preferable to living in a
state hospital in almost every case as long as you stay on your medication.
But if you are living in the community without medication, and you are
homeless and as a study in Los Angeles, 28 percent of the homeless severely
mentally ill, get the majority of their food from garbage cans. This is not
exactly a quality life. If on the other hand, you are in jail and in prison
because of your severe mental illness, this is not a quality life either. So
that I would say of all the people that we have emptied out, we
deinstitutionalized from the hospitals, we've emptied out the hospitals, I'd
say about half of them are better off living in the community but a half are
not better off. They are the ones who are roughly 150,000 severely mentally
ill among the homeless, roughly 200,000 severely mentally ill now in jails and
prisons. This is not a great way to live.

DAVIES: And apart from more effective commitment laws, what should the
national priorities be that will help those people?

Dr. TORREY: I think the commitment laws are extremely important, good
services are extremely important. The way we have organized our services and
funded our services is really chaotic. Much of the managed care has been very
detrimental to people with severe mental illness, especially the for-profit
managed care. We've really done a terrible job of taking care of these people
once they're out of the hospital. The only thing we were good at was emptying
the hospitals. Everything that came after that has really been a disgrace.

DAVIES: It's a big question, but do you need a national health insurance
program to ensure that mentally ill people get the treatment they need?

Dr. TORREY: Well, most of the severely mentally ill don't qualify for most

of the insurance programs we have, and in fact in a sense Medicaid, to a
lesser extent Medicare, Medicaid is the national health insurance for people
with severe mental illnesses. Medicaid is funding more than half, probably
well more than half now, of the services for the severely mentally ill people
in the United States. And it's not really just a question of money. One of
the things that we have found over the years is states that are spending more
money do not necessarily have better services. It's how they organize their
services. And we know how to organize services. It's just the way the
funding system is set up that we don't do it. But it all goes back to the
beginning. If you don't have laws that allow you to treat people who need to
be treated, then no matter how good your services are, it's not going to work.

DAVIES: Well, E. Fuller Torrey, thanks so much to speaking with us.

Dr. TORREY: My pleasure, Dave. Thank you.

DAVIES: Dr. E. Fuller Torrey. His book, "Surviving Schizophrenia," is now
in its fourth edition. You can get more information about the Treatment
Advocacy Center at its Web site, psychlaws.org.

(Credits)

DAVIES: For Terry Gross, I'm Dave Davies.
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