Friday, July 6, 2007

No Asylum

Though the sentiment most associated with Guantanamo is certainly outrage, readers of Kafka can only greet the reports from the world-infamous prison with grim familiarity. The intractable tangle of bureaucratic language and legal jargon that has confounded what progress the executive is willing to attempt – trials canceled because what we once thought were “illegal enemy combatants”, already a dubious conceptual category, have not proven to be discernibly “illegal” but merely “enemy combatants” of a more vanilla variety – recall the unnavigable bureaucracy of the The Castle, while Josef K could only take Jose Padilla as kin.

But long before Guantanamo became the symbol par excellence of America's institutional nightmares and grotesque easiness with egregious human rights abuses, Kafkaesque tales of absurdity and horror could be heard. Or at least they should have been.

Imagine a prisoner. He is in solitary confinement, spending twenty-three hours a day in utter isolation. Typically unsupervised, he babbles to himself, pound the walls with his fists and head. He may come to occupy an entirely hallucinated world. Or he may attempt suicide. He may succeed. If he even consciously committed a crime, his memory of the event may have deteriorated alongside his other capacities. You wouldn't find this man in Cuba. You would find him in New York City. And not just in the past six years, when Guantanamo's dark odyssey unfolded, but at virtually any point in the past three decades.

Solitary Housing Units (SHUs) are the places that too many prisoners call home. They are not easy for anyone to withstand. But for the mentally ill, they are sites of unparalleled suffering. The Department of Justice concedes that 16% of America's inmate population suffers from a diagnosable mental illness. The American Psychological Association and Human Rights Watch estimate that the number is closer to 1 in 5. Depression, schizophrenia, bipolar disorder, and many other acute mental illnesses impact over some 300,000 inmates. For some, mental illness motivated their crime. For others mental illness emerged after imprisonment. But either way, the likelihood that mentally ill prisoners will end up in SHUs is extreme. As Jamie Fellner of Human Rights Watch explains:

They end up in segregation because their illness makes them less able than other prisoners to cope with prison life. They are more likely to be victimized and more likely to be injured in a fight. They are more likely to break the rules. They are more likely to behave in ways that annoy, disgust and even enrage security staff who have scant training in how to recognize, much less cope with, symptoms of mental illness.

Not only are they more likely to end up in SHUs, but solitary confinement is uniquely hellish for inmates suffering from mental illnesses because it virtually guarantees that their condition will deteriorate as their needs go unaddressed. Fellner continues:

The very architecture of SHU facilities, as well as SHU rules, keep them from receiving group therapy, up therapy, individual therapy, daily living skill training, educational and vocational programs, structured and unstructured group recreation and other activities that can play a crucial role in restoring or improving mental health—or at the very least in preventing further deterioration in the patient’s psychiatric condition.

Fortunately, the State of New York has taken action to close this disturbing chapter in the history of America's prison system. S333, once signed by Governor Spitzer, will amend New York's correction and mental hygiene laws so that inmates suffering from mental illnesses will not be eligible for placement in SHUs. All inmates being considered for SHU placement must first be screened by a board of professionals prior to transference. Those found to be suffering from mental illnesses will be placed into special treatment programs where supervision and close treatment are mandated by law. A simple attentiveness has saved hundreds of women and men from a hellish existence, and it is possible that more states will take thus cue from New York. It is certainly welcome news. But it is also a relatively minor step in correcting the sprawling system of bureaucratic shortcomings, institutional failures, and social aporiae that have brought about the system in which the inhumanities described above can occur.

America's health and human services system, sprawling beast that it is, has utterly failed the mentally ill of this country. The web of failed and flagging programs that has produced the deplorable status quo is so complex and mutually reinforcing that it is difficult to even begin the discussion. But one thing is certain: responding to the crisis of mental health care in this country will be impossible within an individualist paradigm. Reinvigorated communities and an ethic of care must have a part in the process – easy enough to theorize, but wickedly difficult to implement since the communities and caregivers in most need of solutions already have their resources stretched thin.

Americans, committed to an ideology where “equal opportunity” is seen as the upper limit on egalitarian obligations tend to downplay inequalities in outcome. And the mantra of “individual responsibility”has dealt plenty of harm to the robust redistributive and welfare-provision policies that would actually be needed to redress the dire inequalities of wealth and assets that cut across America's socio-political landscape.

The dire implications for the mentally ill are made clear in this eye-opening report on mental health care in low income communities. Medicaid and Medicare programs that can't reimburse hospitals enough to even keep sufficient numbers of psychiatrists on the payroll make affordable mental health service hard to find. For uninsured Americans, or for Americans whose providers don't practice parity for mental health, mental health problems may go untreated until a serious lapse lands the sufferer in jail or in an emergency department (ED). Of course, EDs themselves, especially those serving low-income communities where huge numbers of people are on Medicaid or totally uninsured (and on avearage 20% of all mentally ill people are uninsured), have to cut back on which services they can provide and frequently send mental health patients away without treatment, as their emergencies are often easier to ignore than those suffering a physical emergency. Inadequate Social Security payouts are a problem, too. Currently, SSI payments average $632 a month. But a modest, single-bedroom apartment in the United States averages $715 a month. People dependent on SSI for income simply can't compete in the current housing climate. And, of course, many of America's mentally ill, unable to find consistent work, are in precisely that position. So they end up untreated on the streets, often facing prison as the ultimate destination. With all of these support networks – Medicare, Medicaid, Social Security, public hospitals – failing, is it any wonder the prison system has emerged as the de facto “solution” to the problem of mental illness – a solution that looks increasingly like reinstitutionalization?

Some necessary solutions are clear: Medicaid and Medicare must receive more funding, SSI payouts must increase, housing prices may need to be capped or controlled, and government-paid health care (that includes parity for mental health care), needs to become a reality. The government should provide people who cannot afford a place to live and the mental health care they need with the income and assets necessary for survival.

But a more fundamental shift is also necessary. It is interesting to observe the drastic differences in treatment between the developmentally disabled and mentally retarded on one hand, and those suffering from psychological illness on the other. Americans, defying the typical individualist ethos of self-reliance, have by and large stepped up to the plate to provide for the former group (Vladeck, 2005). Many of the coverage caps in Medicare/Medicaid programs have been addressed, and political advocacy has been more effective on their behalf. It seems that Americans can comprehend permanent disability, but the idea that a person may experience episodic mental illness that requires extending the offer of assistance throughout a lifetime, to be taken as needed, strikes many as a blank check for welfare. People must either announce “dependency” (perhaps the most loaded word in the wide lexicon of social policy) or strike out on their own. Gray areas need not apply.

Feminist critics like Iris Marion Young have long pointed out the obvious problem with this ideological construct: most everyone falls somewhere in the middle of the autonomous/dependent spectrum. Those of us who can find all of the care we need within the private sphere – through family or friends – are fortunate, but atypically privileged. Again, it is the most vulnerable, those for whom everyday support structures are inadequate or absent, whose cases force us to reexamine our public policy. But in any event, we should not make the error of believing that it is only those people who are dependent while the rest of us live autonomous lives. The binary cannot stand, and social services ought to be implemented with the diversity of cases in mind. The goal of social policy should be the creation of communities of mutual aid which respond to the emergent needs and crises of members, but perhaps more importantly, support and care for members in affirmative ways that make crisis intervention less and less necessary.

At the level of policy, this might look something like a flexible fund, perhaps created at federal or state-wide levels so that patterns of inequality would not leave the most vulnerable communities with the least funding, that could be applied to support EDs, aid needy people in finding housing, or pay for routine psychological wellness exams for all who consented to them. These types of solutions would encourage communities to come together and analyze their needs, rather than suffering under larger bureaucracies whose shortcomings only become clear in the wake of failure. A community-oriented approach would also empower the mentally ill to participate in and with community aid projects, rather than facing strictly medical/institutional solutions that dehumanize on the basis of condition.

In short, a socialism that is truly “social” will emphasize community and communication as means of empowering and nurturing the most vulnerable segments of society, rather than expecting the kind of harrowing systems that have been producing incomprehensible no-exit nightmares since Kafka's day to do the work of justice. Nowhere is the need for such a revolution in thinking more apparent than in the crisis facing the mentally ill today. With their fate so firmly in the hands of ailing bureaucracies, the mentally ill in America are often the hapless playthings of a system that is dully malevolent in its neglect. Where the status quo produces Kafkaesque vertigo, it is incumbent on all who see the social bond as a site of obligation to respond with care.

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