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‘Minds on the Edge’ Explores Public Policy Hurdles of Mental Illness

January 18, 2011 at 4:00 PM EDT
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The "Minds on the Edge" seminar, hosted by Fred Friendly and airing on many public broadcasting stations, explores the public policy dilemmas facing some people with mental illness and the communities in which they live.

GWEN IFILL: Finally tonight: how mental illness challenges public policy.

The Tucson shootings forced that issue back to the front burner, but it’s a debate that never really went away.

This week, public television stations will rebroadcast “Minds on the Edge,” a Fred Friendly seminar featuring a panel of distinguished jurists, doctors and mental health experts.Together, they address a hypothetical dilemma, in this case, the fictitious case of James, a 32-year-old schizophrenic whose mother has recently died.

Frank Sesno of George Washington University is your guide.

FRANK SESNO, George Washington University:Elyn Saks, James, can you give us a sense of what he’s experiencing?

ELYN SAKS, author, “The Center Cannot Hold”:Sure.

I think I actually have special insight, because I have experienced those things myself.I’m a person with chronic schizophrenia.

The best way to describe having a psychotic episode is like a waking nightmare, where things are crazy, bizarre, frightening, confusing.With schizophrenia, you have delusions and hallucinations and disordered thinking.Like, I was on the roof of the Yale Law School, and I was saying, “Someone’s infiltrated our copies of the legal cases.We’ve got to case the joint.I don’t believe in joints, but they do hold your body together” — so, loosely associated words and phrases.

But, experientially, the — the feeling is utter terror.

FRANK SESNO: And James is feeling very alone.

ELYN SAKS: He needs support.Everybody needs support.And there are resources available, community mental health centers.So, it might be useful for him to contact a social worker at a community mental health center and get some kind of support in his life.

FRANK SESNO: James is feeling very alone, as you said.And he’s scared.And he’s staying in his apartment.He now can’t go to work.He’s paralyzed.


FRANK SESNO: He loses his job.


FRANK SESNO: But, in a moment of clarity, he does know he needs help.


FRANK SESNO: And where he knows to go is, again, the emergency room.


FRANK SESNO: But they’re overflowing.They say they can’t help.But they do want to commend him to an outpatient clinic, Commonwealth Clinic.And, so, they give him an appointment there at 3:00 on Wednesday, three weeks from now.



FRANK SESNO: Surprise you?

SAM TSEMBERIS, founder, Pathways to Housing:No.It’s — it’s all too familiar and disappointing, that very few people referred out of emergency rooms actually make it to out patient clinics.

He needs a different kind of an approach. He needs a — an intensive case manager that can actually escort him out of that emergency room to the next…

FRANK SESNO: Wait, wait, wait, wait.They’ve given him an appointment, and he’s not even going to end up there?

ESTELLE RICHMAN, Pennsylvania secretary of public welfare:Oh, no.James doesn’t — probably doesn’t wear a watch.He’s already disoriented.He doesn’t know three weeks from three months.

ESTELLE RICHMAN: He’s not — he doesn’t track time well right now.He’s in his illness.

FRANK SESNO: But he wanted treatment.

ESTELLE RICHMAN: As you said, they’re crowded. They say: “Here’s your medicine. It will make you better. Here’s your appointment.”

And, by the way, they have a record on James.This isn’t his first.He’s been receiving medication.And they could say, you know, we’re going to send you back to the Commonwealth Behavioral Center.But if he’s in an active psychotic episode right then, he needs treatment now, not in three weeks.

LAUREN SPIRO, director of public policy, National Coalition of Mental Health Consumer/Survivor Organizations: James is absolutely in crisis. And his mom has just died. This is a major crisis. And, of course, he’s going to have very strong feelings about it. And being locked up — or — or bringing in police, or — that’s really scary. That is going to escalate. If I’m James, that’s going to escalate me. I need a safe place.

FRANK SESNO: You tell me this happens all the time.

ESTELLE RICHMAN: He will not be admitted.He has not represented any danger to himself or others.They will not keep him.And they will treat him as another person coming through that emergency room.

FRANK SESNO: So, James walks out with his appointment three weeks from now…

ESTELLE RICHMAN: And maybe a prescription — maybe.

FRANK SESNO: … and maybe a prescription, and is disoriented.He is now about to have something else happen.

ESTELLE RICHMAN: That’s right.

FRANK SESNO: He is arrested…

ESTELLE RICHMAN: That’s right.

FRANK SESNO: … for public urination. He now goes, not to the hospital, Judge Leifman, but to…

JUDGE STEVEN LEIFMAN, 11th Judicial Circuit, Miami-Dade County, Florida:Jail.

FRANK SESNO: Surprised?

JUDGE STEVEN LEIFMAN: Not at all.Judges are much more likely to see consumers with mental illness than psychiatrists.

FRANK SESNO: Judges are more likely than psychiatrists to see people…


FRANK SESNO: You see more people with mental illness than Dr. Skale here?

JUDGE STEVEN LEIFMAN: Probably 10 times more a day than — than she does.

FRANK SESNO: What is going on here?

JUDGE STEVEN LEIFMAN: Well, he’s committed a crime.And a law enforcement officer is there to enforce the law.

We have over a million people a year, arrested in this country with severe mental illnesses — over a million.

FRANK SESNO: Pete Earley, step aside from your role for a minute, and speak as a journalist.What’s happened here?

PETE EARLEY, The Washington Post:Well, in the ’60s and ’70s, we had a little under a million people in state mental hospitals.And many of these places were horrific places.We started closing them down.We never built the community system necessary.

Today, there are less than 55,000 people in state hospitals.There are 300,000 with bipolar disorder, schizophrenia, and major depression in jail, 500,000 on probation.That’s due to two things, in my opinion: no community safety net and laws that say a person has to be of danger before anyone can successfully intervene.

ESTELLE RICHMAN: James doesn’t get kept in — in jail.There’s not room.He hasn’t committed a major — major crime.

The worse scenario is, the police say, you know, “Don’t do it again.” They put him on the street.

THOMAS SIMPATICO: He just may go off the radar screen and quietly — live somehow out of dumpsters.And, if he’s lucky, if he happens to live in an area where there’s a competent and — and dedicated group of outpatient psychiatrists and treatment systems, he may have the good fortune to cross paths with that, and they may be able to help him.

But, if I were playing the odds, across the country, I think the likelihood of that happening is fairly remote.

JUDGE STEVEN LEIFMAN: It’s almost an impossibility.

FRANK SESNO: An impossibility?

JUDGE STEVEN LEIFMAN: If you listen to this, don’t you understand that the mental health system is the definition of insanity at this point?

We keep doing the same thing again and again, and we expect a different outcome. It will not change until the system changes. What’s most likely is going to happen, he may run into the same police officer. And the officer says: “You know what? I took him in on a misdemeanor, and they let him right out. So, now, you know, he ran away from me. I’m going to charge him with a felony.”

So, he’s going to come into the felony system, and he’s going to sit eight times longer than someone without mental illness for the same charge, because we don’t know what to do with him.And we’re going to get him into a forensic state hospital, so we can restore his competency, not so we can get him back to the community for treatment — so we can try him and send him to prison or jail.

In Florida, a third of our mental health money is going to 1,700 beds to restore competency.And then there’s no money at the front end to keep people out.That’s your reality.

ESTELLE RICHMAN: And your odds of being in the right place at the right time are pretty low.The money in some states is more readily available than money in other states.

The problem is, we refer to it as a system, and it isn’t a system.And it is lots of things that are sort of put together almost by bubble gum, as opposed to by any plan.And the goal for most of us in policy-making positions is to try to untangle it enough to create a system.

GWEN IFILL: This Fred Friendly seminar on facing mental illness can be seen on most PBS stations this week. Check your local listings. And join the dialogue online at