DEENEY: Let Us Now Praise Jill Porter

deeneythumbnail.jpgBY JEFF DEENEY Jill Porter deserves to be spotlighted for her column about Thomas Scatling, which is a refreshingly even handed and well informed take on the man behind the Broad Street subway hammer attack.  Porter focuses on the question of whyScantling was on the streets as opposed to under long term care at a mental health facility despite the fact that he was 302ed, or involuntarily committed, just weeks before the incident. Scantling had a history of violent behavior and was no stranger to the mental health system and the criminal courts.  So why was he on the Broad Street subway in the midst of a psychotic episode, accompanied by his small child and carrying a hammer?  Porter gets right to the brass tacks:

Even when patients need continued treatment, they’re often let go at the mental-health hearing that’s mandatory after the initial three days of involuntary hospitalization. You can guess the reasons.

Not enough hospital beds.

Not enough insurance coverage.

In other words: money.

Scantling’s story is actually not uncommon.  Due to a general lack of viable long term treatment and housing options, the city’s most severely mentally ill, many of whom also live on the streets, repeatedly cycle in and out of the prison and mental health systems.  Sometimes they appear in mental health courts on a monthly basis.hammerattacker.JPG

When someone is 302ed they are put on 72 hour lock down in a mental health facility, during which time they will appear before a mental health court judge who will determine whether or not to extend the involuntary stay.  Oftentimes they are released to the streets at this point, despite the fact that many, like Scantling, display a clear need for further treatment.

Sometimes this happens because, as Porter pointed out, resources are scarce and the mental health system is heavily strained.  Other times it has to do with the decision made by the mental health court judge, who, unless given compelling reasons to keep someone on lock down will side with the patient.  These patients don’t want to be locked down in a mental health facility, as is implied by the involuntary nature of their stays.  Usually they are more than happy to walk out of court a free person despite the fact that they are still sick.  Who wouldn’t?  Mental health facilities can be bleak places.  Even if it was in your best interest you might not want to stay in one, either.

There’s good reason for the court to side with the patient in the absence of compelling evidence that long term treatment is needed.  A long term involuntary commitment to a mental health facility is tantamount to incarceration.  Just as the commonwealth shouldn’t send people to prison without evidence that they committed a crime, it shouldn’t lock people up for extended stays in mental health facilities without evidence that they require such high intensity treatment and observation.

Scantling’s case is troubling, though, because this evidence was presented to the courts.  One of the biggest factors in swaying a mental health court judge to mandate an extended stay in a mental health facility is the presence of a petitioner, usually a family member though sometimes a social worker, who can testify to the severity of thepatient’s illness and their inability to function in the community.  Scantling’s family petitioned the court and presented evidence that he wasn’t functioning in the community.  Scantling walked, anyway.

The object of an extended stay in a mental health facility is to give patients a chance to establish a behavioral baseline where they are no longer psychotic, are responding to medication and understand what their immediate needs and goals are and have a plan to achieve them upon returning to the community.  During their inpatient stay they may be assigned to case management services with a community mental health agency that will work with them after they leave.  If needed, they can be connected to housing resources, disability income, and other entitlement programs.  They can be educated about their illness, and learn to watch for signs of “decompensation,” or the onset of psychotic symptoms.

Without an extended stay in a mental health facility to achieve this baseline, severely mentally ill patients return to the community just a bad off as they were when they were committed.  This makes life difficult for social workers assigned to provide them community based case management services. Many clients disappear the moment they hit the streets, and others are resistant to treatment and unwilling to take medications.  When clients begin todecompensate , sometimes only days after their last release, they become suspicious of their treatment team and withdraw further from other community supports like family or clergy members.  From this point it’s only a matter of time until they act out again in a way that lands them back in mental health court.  From a social worker’s standpoint, it’s incredibly an frustrating cycle that requires a tremendous amount of patience if it is to eventually be broken.

I’ve worked with this kind of community mental health program, and worked with clients like Scantling who had extensive histories of psychotic and assaultive behavior.  Working with this population in the community is hard enough without the system falling down when the client needs fall back on it.  On many occasions the treatment team I worked with was frustrated by court decisions to let clients walk before we had a chance to meet with them in an inpatient setting.  We were equally frustrated by mental health facilities, who routinely released clients at the earliest possible chance despite our advocacy for them to receive further treatment.   We protested that without adequate time to arrange housing resources they were essentially putting our clients back in the streets.  We were usually told that inpatient bed space was too tight to keep people in the hospital waiting for beds in the community to free up.

The sense I had while working with community mental health providers was that most felt the system worked consistently against the best interest of their clients.   Funding concerns that lead to constraints on long term treatment options, poor mental health treatment within the prison system and a lack of adequate supportive housing options hamper the recovery of many severely mentally ill men and women.  Many of these men and women wind up living in the streets and suffering from psychotic symptoms as a consequence, and sometimes those psychotic symptoms lead to erratic or violent behavior.  The case of ThomasScantling provides a worst case scenario for happens when the mental health system fails, and underscores how important it is to the well being of the community at large that the sickest among us receive adequate services and necessary treatment.

ABOUT THE AUTHOR: Jeff Deeney is a freelance writer whose work has appeared in PW, City Paper and the Inquirer. He focuses on issues of urban poverty and drug culture. He is currently working on a book about life in the crossfire of poverty, drugs, guns, and the bureaucracies designed to remedy them, all of which informed his experiences as social workers in some of the city’s most dire and depleted neighborhoods.

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