Dangerous? It's Not That Simple.

The issues that surround mental health cross the boundaries of many disciplines and make up one of the most varied groups of stakeholders of any issue. It is impossible to examine mental health issues without crossing purposes with a number of different interest groups. It a way, the groups of stakeholders are representative of the complexity of the disorders themselves, defying simple labels and diagnoses. While other diseases are similarly complex and varied, none of them cover a range of social issues as broad as mental health.

Cancer, while seeming to be a unifying concept, touches diet and exercise, various organs, surgery, drugs and a host of causes, both environmental and lifestyle in nature. But unlike mental illness, it does not seem to cross into the realm of public safety and law enforcement.

Mental illness seems to be unique in that it touches not only the person affected by the disease, but often times people around the affected person. When the behavior of the person affected is involved, a whole new level of complexity of the issue is at stake. That seems to be why stigma has developed around disorders of the mind, the twin issues of complexity and potential for danger. Most often this is expressed legally as "danger to self or others."

The problem used in that legal expression is the threshold of the danger posed. Clearly this is a confounding problem and generates the most disagreement among those who take positions regarding how we as a society view the treatment and diagnosis of mental illness.

Philosophical worlds collide both before and after events which are judged both by what happened and what is thought to be the state of the mental condition of the person who is being judged. It is because of the potential for explosive and damning results that most positions are fixated based upon existing beliefs and viewpoints.

The collisions are very apparent in the dilemmas that state legislators are faced with in defining treatment plans for those who have been placed in the custody of the state who are "guilty except by reason of insanity." The dilemma is what to do with those who fall into this category.

Simplistic rules of morality might suggest that the best way to handle such a situation is "You do the crime, you serve the time." The problem with this manner in viewing the problem comes from two perspectives and creates some no-win scenarios. First of all, it is extremely difficult, if not impossible, to be certain of the state of a person's mind at the time of the crime. Secondly, some mental diseases result from not what might be classified as psychotic thought, but delusional thoughts.

A prime example of this situation is the case of Andrea Yates who drowned all five of her children in a bathtub. Mrs. Yates was arguably a person of substantial intelligence. She was valedictorian of her high school class. She was "aware" of her actions to the extent that she phoned police and was able to describe what she had done to the children. Given that information, some conclude that she was a cold-blooded killer. However; she was operating under assumptions of fear that her children were condemned to eternal suffering and she was "saving" them from her being an unfit mother.

Does the definition of insanity include distortions of logic and reality? Because the disorders are defined by DSM-IV behaviorally, the simple answer is yes. When does that depart from what society calls insane? Several times I have listened to people diagnosed as mentally ill tell their stories of "distorted" reality and "voices" driving their behavior. Are there really people who might suggest that Andrea Yates felt that she had something to gain by killing her children? For most people the thought of killing your own children is beyond their ability to conceive of such a vision of reality. In the case of Andrea Yates, not only was such action plausible, it was in her version of reality the only reasonable course of action to save her children.

Does that make Andrea Yates ill or a horrible murderer? The answer is a conflicting "both." She did in fact, kill her children. She did not, however, kill them for personal gain nor intentionally with malice, she killed them from application of a bizarre sense of beliefs and logic that almost anyone else would not accept. I would argue that distinction is where much of the controversy about mental illness lies within society today.

Society argues about propositions of "reality" every single day. There are those who argue that global warming is a reality. There are those who argue that it is a concept put forth by false science. The question becomes which reality is essentially "real?" To Ms. Yates, her reality as expressed by her behaviors was that her children were better off dead than subjected to her "perceived reality" of eternal suffering. Try and imagine the mental state of a person who would make such a choice and you may begin to understand how convinced she must have been to take the actions that she took.

In a similar fashion, people who take their own lives follow the same path of logic. Their decision is based upon a vision of their reality at that point in time that makes no sense to most people, yet research tells us that many people who take their lives experience a sense of relief after having made the decision to end their lives. At that point, the angst over the decision to take the suicidal action is replaced by a relief and the actions become a kind of surreal expression of of the fulfillment of a logical progression, flawed as it is. The result in the Yates case is the expression of a calmness and detachment over having fulfilled an action that resolved the situation. It is only later when a realization of the "other" reality sets in that the actions seem to impact the person. In the case of suicide, however, the "solution" is permanent and irreversible.

From a broader perspective, what is the function of the state in protecting people from potential harm, and where are the boundaries? In the Yates case, Andrea had received care for depressive episodes but her mental health benefits had been exhausted. Her mental health professional had suggested that she not have any more children as that would nearly certainly trigger another episode of severe depression. Her husband had vigorously suggested at the urging of a spiritual advisor that she procreate and bear all children that she could possibly bear. The mental health provider suggested that she was not to be left alone with the children as she could be dangerous, but her husband had thought it was advisable to give her short trial periods alone with the children to keep her from becoming too dependent upon him.

Like most stories, there are circumstances that go well beyond the initial headline that complicate the issues of the case. Some mental health and personal freedom advocates suggest that court systems strip away individual rights and force inhuman treatment. Some suggest people should be free to do as they will. Others, in defense of their perceived safety, want any person with mental health difficulties segregated and locked away.

Answers to these issues are being forced by legal and treatment systems in place. No answer in the extreme is helpful nor particularly effective. Neighborhoods are not necessarily safer because group rehabilitation homes are refused to be located there. There are, without question, predators that are yet to be identified that cannot be relocated away from schools and children. Even recent lawsuits surrounding the behavior of members of the clergy have suggested that dangers lurk in places previously presumed safe. Clearly, society needs to understand the problems better and find more comprehensive measures to treat people in crisis. To believe that there are perfect solutions available is foolish, but to believe that we can do no better than we are doing is equally lacking in wisdom.

One conclusion is certain. Not treating people and not discussing the problems surrounding the issue is not helpful.