One of the more troubling issues I have encountered in my 15 years of the practice of psychiatry is the frequency with which agencies work to evade responsibility and accountability for the clients they are supposed to serve. No agency is immune to this problem, but in my experience, one of the most egregious situations goes something like this:
Joe is a 33 year old man seen on the grounds of a local elementary school. He is not recognized by school staff, and the police are called. Upon approach by police officers, he appears not to understand their direction to leave the grounds.
Instead, he approaches the playground area where the kindergarten class is currently playing. The police officers take hold of his arms, at which point Joe begins screaming and fighting to extricate himself from their hold. He is charged with trespassing on school grounds, resisting arrest, and two counts of assault on a law enforcement officer.
Upon entry into central booking, Joe does not answer any questions, instead sitting rocking on the bench. Other arrestees tell detention staff “there's somethin' wrong with that dude – he's crazy!” Joe is referred for an urgent mental health assessment, where he stares over the evaluator's head as if seeing someone behind the clinician. He is placed in the mental health area of the booking center and a psychiatrist is called. The psychiatrist diagnoses Joe with schizophrenia and orders antipsychotic medication, which Joe refuses. When taken for his bail review three days after his arrest, the court orders a competency assessment, and Joe is placed on the list for a forensic psychiatric evaluation.
When seen for the evaluation at the court clinic, Joe is still generally silent, but at times he echoes the last words of the questions posed to him. He is found by the forensic evaluator to be incompetent to stand trial, and he is committed to the hospital for treatment and restoration to competency. During his stay at the hospital, staff eventually are able to engage Joe sufficiently to track down Joe's mother, who reports that “Joe was always a bit off. He was in special education classes at the school where he got arrested.” When records from the school system are sought, the hospital staff are told “FERPA requires us to destroy special education records after 5 years.”
What is Joe's real diagnosis? It appears that instead of schizophrenia, Joe has a developmental disorder such as autism or a similar pervasive developmental disorder. These types of disorders require very different treatment and rehabilitation approaches from the more familiar mental illnesses like schizophrenia or bipolar disorder. Typically, mental illnesses respond to medications, while the developmental disorders require a more comprehensive behavioral approach.
More problematic is the system of care. In many – perhaps most – states, one agency is responsible for the care of people with mental illness, and another is responsible for people with developmental disabilities such as autism or intellectual disabilities (formerly known as “mental retardation”). Whereas people with mental illness can be hospitalized urgently if they meet civil commitment criteria (problem enough, as discussed in my June blog entry), those with developmental disabilities must prove that they are sufficiently impaired and that the impairment began in childhood before benefits are provided. As the vignette illustrates, the childhood origin can be difficult to prove even when it is known where the individual attended school; it is often impossible to get even this information, if the person is unable to communicate or if he is from another country. Thus, individuals who really require a behavioral approach to remedy or address their deficits end up in a psychiatric system that cannot say no, that is ill-equipped to manage them, and they are often inappropriately treated with medications that cannot be effective and that only lead to adverse effects over time.
I have consulted on cases and systems in many states, and I always hear the same thing: “How can we get these agencies to coordinate better?”
Erik Roskes is a forensic psychiatrist and currently the Director of Forensic Services at the Springfield Hospital Center in Maryland. The opinions expressed are those of the author only, and do not represent those of any of Dr. Roskes' employers or consultees, including the Maryland Department of Health and Mental Hygiene. He can be found at http://mysite.verizon.net/eroskes/