Some thoughts on Jared Loughner and Henry Cockburn

On May 25^th the Washington Post reported that Jared Loughner was judged not competent to stand trial:

A federal judge ruled Wednesday that shooting suspect Jared Lee Loughner is mentally unfit to stand trial for the Jan. 8 rampage in Tucson that wounded Rep. Gabrielle Giffords and killed six, citing expert testimony that Loughner is schizophrenic and shows a paranoid distrust of his own defense attorneys.

Facing an agitated Loughner in a Phoenix courtroom, U.S. District Judge Larry A. Burns remanded him to a federal facility in Springfield, Mo., where he will receive treatment aimed at restoring his competency. The judge ordered that Loughner be treated for up to four months, and if he is then deemed to be competent, the case against him could resume. If not, he could remain in treatment.

Against his defense attorney’s protests, Loughner is being forcibly medicated as Slate reported today:

A federal judged on Wednesday ruled that doctors can force Jared Lee Loughner to take antipsychotic drugs in an effort to make him fit to stand trial for the shooting of Rep. Gabrielle Giffords and 18 others.

“I defer to medical doctors,” U.S. District Judge Larry Burns said at an emergency hearing requested by Loughner’s lawyers, according to the Los Angeles Times. “I have no reason to disagree with doctors. I didn’t go to medical school.”

The purpose of the medication is simply to reduce the most glaring symptoms of schizophrenia so that Loughner can comport himself “normally” in a courtroom. When you stop and think about this, you realize that the forces of law and order are far more irrational than the defendant. He, at least, has an excuse: a chemical imbalance in the brain. They have none except a desire to take vengeance against a person who was “not capable of distinguishing between right and wrong” during a psychotic break, to use the wording that was invoked in the past in insanity pleas.

When you administer anti-psychotic medication to a schizophrenic, it does not mean that the disease goes into some kind of remission, to use an analogy with chemotherapy and cancer. The person remains deeply disturbed, subject to what specialists call a “diminished affect”, inappropriate responses (laughing at a sad story and crying at a joke), etc. The likelihood that patients will do violence to others or themselves is diminished when they are under medication. But all medical experts will acknowledge that when someone like Jared Loughner kills, it is not done willfully. Furthermore, punishing someone like him is not likely to dissuade other unmedicated schizophrenics to “behave themselves”. In bourgeois society, punishment is often explained as a need to deter future crimes. But putting a schizophrenic behind bars is simply barbaric.

While it was difficult to defend someone charged with a capital offense in the past, it was not impossible. All that changed after John Hinckley shot Ronald Reagan. In the three years following the Hinckley acquittal, half of the states passed laws limiting use of the defense. One state, Utah as might be expected, abolished the defense outright.

Bourgeois society is so anxious to punish the mentally ill when they commit crimes because of deep-seated phobias. The terms “crazy”, “mad”, etc. are used mostly to describe bad behavior of politicians, etc. but they are never completely detached from the human beings who as the old insanity plea put it, are incapable of distinguishing right from wrong at the time of the act.

As might be expected, such prejudices ran deep in Victorian England. Despite this, Daniel McNaughtan was found not guilty by reason of insanity for killing Prime Minister Robert Peel’s secretary. McNaughtan was under the delusion that Peel was persecuting him. Both defense and prosecution experts agreed that McNaughtan suffered from paranoia schizophrenia. The McNaughtan plea was a legal precedent in both the USA and Britain until Reagan was shot.

As an indication of how wrong the perception of the mentally ill can be, the NY Times led the pack in an article that appeared on October 27, 1981:

A Secret Service agent, a Federal Bureau of Investigation agent and a police officer testified today that John W. Hinckley Jr. responded clearly and rationally when they questioned him a few hours after President Reagan and three other men were shot last March 30.

”At one point, I couldn’t spell assassinate, and he spelled it for me,” Arthur E. Myers, a District of Columbia homicide detective, said in describing his questioning of Mr. Hinckley the afternoon of the shootings.

Whether Hinckley could spell the word or not had nothing to do with his state of mind on the day he shot Reagan. The fact that he did it to “impress Jodie Foster” was much more important, as well as how he fared on a standard psychological examination that is used to diagnose schizophrenia.

Like Jared Loughner, John Hinckley became a convenient target for society’s phobias against the mentally ill, so much so that it took nearly 25 years for him to gain the right to visit his parents overnight. Considering that nobody died as a result of his attack, such vindictiveness seemed inappropriate. Furthermore, one wonders how he would have made out if his parents had not been so connected. His father was president of the Vanderbilt Energy Corporation as well as World Vision, an evangelical relief organization with a budget exceeded 2.6 billion dollars. Imagine if Hinckley had been the African-American son of a single mother.

* * * *

Fortunately for Patrick Cockburn, his son Henry never attacked another human being violently. Mostly the violence was inflicted on his own person, usually taking the form of swimming in cold and turbulent waters in the middle of winter or scaling tall walls.

For eight years Patrick Cockburn and his wife Jan had to cope with Henry’s repeated temptations with fate, as he escaped from one mental hospital or another and went about his death-defying odysseys of the streets and wooded areas of the cities where he was confined.

This year Cockburn wrote a book about his experience looking after Henry, with a few chapters penned by his son. Titled “Henry’s Demons”, it is a supremely frank and courageous work that I will probably have more to say about at some point. But for now, I want to share Patrick Cockburn’s take on the state of mental health facilities in Britain and elsewhere. It is a sad but accurate commentary on the conditions that will guarantee more loss of human life like which occurred in Tucson:

The facilities at DVH were so poor and supervision of patients at the Bethlem Royal so lax partly because of radical changes in the way the mentally ill have been treated in Britain, Western Europe, and the U.S. over the last half century. Health experts increasingly see some of these developments—however well meant at the time— as a catastrophic setback in the care of those with mental disorders. Henry suffered from this revolution in mental health care, and mistakes were made in his treatment, but he was also looked after by dedicated and highly skilled doctors and nurses and was less seriously affected than many others. He was lucky to come from East Kent, where provision for the mentally ill has a reputation for being better organised and implemented than in much of Britain. The East Kent Mental Health Trust unstintingly sought effective treatment for him despite many setbacks. Even so, the options available to officials of the trust were largely determined by the fact that the old system of mental asylums, built in Victorian times and in the first half of the twentieth century, has been mostly dismantled over the last fifty years, and too little has been done to replace it. Prisonlike many of the old asylums may have been, but at least they were a haven for people too mentally ill to find work, food, and shelter for themselves. Inside their walls, life may have been institutionalised, but one could safely behave bizarrely or even madly without derision or persecution.

Certainly the alternative to the mental asylums has generally proved worse than what went before. In Britain this went under the attractive-sounding name of “care in the community,” which must be one of the most deceptive and hypocritical phrases ever devised by a government. It was claimed at the time that big psychiatric hospitals would be replaced by a network of outpatient clinics, halfway houses, and hostels overseen by specialist psychiatrists, doctors, and nurses.

In reality, British Health Minister John Hutton said in 1999 “the present system of care in the community has actually become ‘couldn’t care less’ in the community.”

As asylums closed en masse in the 1980s, those who once found a measure of protection in them had nowhere to go and were sometimes thrown onto the streets, becoming “sidewalk psychotics”; were sent to prison; or, more usually, were looked after by their overburdened families. Between the 1950s and today, the number of beds available to psychiatric patients in Britain fell from 150,000 to 30,000. In the U.S. a similar shutdown of mental asylums was presented as “dein-stitutionalisation,” a word which has a fine libertarian ring to it until one realises that many people with mental problems have a desperate need for an institution to protect and look after them. In the U.S. the number of beds available for psychiatric patients in public hospitals fell 90 percent, from 558,000 in 1955 to 53,000 in 2005. Many patients became homeless and were dealt with by the police rather than by health workers. An expert report on the shortage of hospital beds for the mentally ill notes sardonically that the three largest de facto psychiatric institutions in the U.S. today are the Los Angeles County jail, Chicago’s Cook County jail, and New York’s Rikers Island. The worst of the old asylums may have been hellholes, but the response should have been their improvement, not their abolition.

The British detective-story writer P. D. James, who worked as an administrator in the British National Health Service in London when “care in the community” was being introduced and whose husband was a long-term patient in a mental hospital, comments bitterly that community care “could be described more accurately as the absence of care in a community still largely resentful or frightened of mental illness.” The policy greatly deepened the anxiety of families, who often have to rely on their own very limited resources to look after a mentally ill relative. Jan and I were able to find a bed in a mental hospital for Henry easily only because he was so acutely psychotic that there was no doubt about his being sectioned. Sectioning by a doctor meant that a hospital had to find room for him, while people who are only a little less sick are sometimes not sectioned because doctors know there are too few resources to treat them. Twenty years earlier, there would have been no such problem in Canterbury, because just to the west of the city was a mental hospital called St. Augustine’s. It had beds for two thousand patients as well as specialised education units for adolescents and adults with mental disorders.

But by the time Henry became ill, the hospital had been closed down and its grounds sold off for a housing development.

Even now the cruelty and unnecessary misery stemming from the dissolution of the mental asylums in the years after World War II is astonishing. That it happened with so few public protests, perhaps because the victims could not speak up for themselves and were regarded with dread by the wider public, is a surprise and a shame. The public went along with the closures because some hospitals were very bad, and even those which were good had wards where insane people were confined in appalling conditions. As these psychiatric hospitals came under attack, it was easy to demonise them as the dumping grounds for people who had breached social conventions of the day, such as girls with illegitimate children. In addition, medical staff had used electric shock treatment, which was traumatic for patients and showed little benefit. And movies like One Flew Over the Cuckoo’s Nest reinforced the perception that such institutions were prison camps misruled by authoritarian monsters.

Mental asylums became the targets of criticism from an odd but influential coalition of civil-rights liberals and fiscal conservatives.

Radicals like R. D. Laing argued that people with mental disorders were the victims of their families and could be better treated outside mental hospitals. The so-called father of community care in Britain in the early 1960s was the right-wing libertarian Conservative health minister Enoch Powell, later notorious for his attacks on immigrants and immigration. The big psychiatric hospitals had few defenders.

Governments and health officials eager to save money made common cause with liberals and the left, who saw mental patients as prisoners unjustly incarcerated. In reality, no group of people is more vulnerable or less likely to be tolerated—still less cared for—by a public viscerally frightened of madness. An important motive for closing down the big asylums was expense. Mental health care is costly; many people at hospitals like St. Augustine’s in Canterbury were incurable, there for life. At one facility for accommodating, treating, and educating mentally disordered adolescents, also near Canterbury, costs per patient in the 1980s were five times the fees of Eton, Britain’s most aristocratic boarding school.

Not all the motives for closing down the mental asylums were mercenary or mistaken. People might often be ignorant of how the mentally ill were treated, but they had a vague sense of guilt that patients had been hard done by in the past. Warders at the original “Bedlam”—the modern successor of which is Bethlem Royal–had been notorious in the eighteenth century for making money by charging visitors in search of amusement to watch the mad antics and delusions of patients. When I was a boy in the 1950s, psychiatric hospitals were familiarly called “loony bins,” a phrase evoking images of padded cells and straitjackets.

Getting rid of this system began to appear all the more feasible in the mid-1950s thanks to the discovery of effective anti-psychotic drugs.

These could usually control the most exotic and dramatic hallucinations and voices, though they were less successful in dealing with passive symptoms such as apathy and inability to relate to others. By the late 1970s and early 1980s, the use of depot injections, whereby the drug gradually disperses into the bloodstream, meant that some but not all medication could be administered by a nurse once a fortnight. This made compliance with the medication automatic and appeared to make it unnecessary for a mentally ill person to be resident in a hospital or even to see a doctor frequently. Though depot injections made treatment easier and more certain, psychiatrists overestimated what such medication could achieve. Their perceptions were reinforced by research funded by pharmaceutical companies, which put medication at the centre of all treatment and downplayed therapy and the beneficial impact of an improved environment.

As the old mental asylums closed, care in the community could have worked only if it had been sustained by a network of psychiatrists, social workers, and clinics. This system never existed and was never likely to be created because it would have high costs and governments had closed the asylums partly to save money. Public protest over what had been done was limited. The one time the public appeared to wake up and become conscious of the inadequacy of the new arrangements for the mentally ill was when there was a spectacular murder by a person with mental health problems. There are at least fifty such murders in England every year, though more people are murdered by drunks than by the mentally ill. When there is a murder by a mentally ill person, there is often a brief and usually ill-informed debate on why a potential killer had not been hospitalised and was on the loose despite many warning signs. Some who later committed murder had vainly sought to get themselves admitted to a hospital only to be told that there were no beds available. An unfortunate effect of such episodes is to reinforce the pariah status of those with mental disorders and to scapegoat doctors and social workers for not sending potentially dangerous people to mental hospitals, ignoring the fact that these institutions are now few and far between.

Fear of madness and the mad is probably less than it was, and campaigners for the mentally ill congratulate themselves on reducing stigma. But fear of those believed to be insane was one reason the Victorians allocated so many resources to building mental asylums. A schizophrenic patient is a hundred times more likely to kill him-or herself than to kill somebody else. But the connection between schizophrenia and violence is a little stronger than is openly admitted by many psychiatrists. About 8 percent of offenders who murder or attempt a murder have schizophrenia, and schizophrenic patients are four times more likely to be involved in violent incidents than people who have not been diagnosed as having a psychosis. An indication of how care in the community has, in practise, meant abandoning the mentally ill to their own devices is that the majority of schizophrenic offenders in Britain were known to the psychiatric services but were not receiving treatment at the time of their offence. Reducing the stigma and ignorance surrounding mental illness is beneficial, but it risks undercutting the case that those suffering from it desperately need expensive special treatment and facilities.