I was walking home the other evening. Replaying the highs and lows of the day. Deep in thought. The activity on the street was barely a murmur in the background. Until my gaze fell upon an old, disheveled man wrapped in ill-fitting clothes and blankets who, with agitation and clear disorganization of thought, was pontificating about topics that were impossible to decipher. His grocery cart beside him, it was bursting with ragged plastic bags of garbage and personal belongings. Without conscious thought, I crossed the street to continue my walk undisturbed.
And when I realized what I had done, disturbed doesn’t begin to capture how I felt. Don’t I know better? I have years of professional training and decades of experience working with Individuals with serious mental illness. I know they are not dangerous. I know that the “othering” of people with mental illness only perpetuates the stigma associated with these health conditions. I know that people with serious mental illness are at enormous risk for losing all meaningful social relationships because of their illness. What happened?
1. Why did I cross the street? Maybe because it is coded deep in our evolutionary history to avoid what we do not understand, particularly if we feel threatened. We are hard wired with a ‘fight-or-flight’ response to such situations. Our ancient ancestors could either fight or flee when they perceived danger. They learned to fight off the attack of a wolf and run from fire. But what was it that was so dangerous in my case? The data are abundantly clear that it is extremely rare for an individual with serious mental illness to be a threat to another person. Just the opposite. It is highly likely that individuals with serious mental illness will be the victims of violence.
2. Why would we be evolutionarily be primed to flee? It makes sense that we have evolved to avoid contact with individuals or groups where we perceive danger. And when it comes to protecting our health, we engage in all kinds of behaviors to avoid the contagion of illness – from covering our mouths when we cough to not touching someone’s leg that is covered with poison ivy. We avoid contact with those who we perceive to carry health risk. The thing is that mental illness is not like the flu or poison ivy. But, evolutionarily, we didn’t understand how people developed mental illness and we learned to flee. There is still much we do not understand today. But we do know that mental illness is not contagious. And thus, we need to intentionally override this evolutionary inheritance that sets us up to distance ourselves. it doesn’t serve anyone.
3. Ashamed and helpless on the other side of the street. It all happened without my even thinking about it, but I know better. I know this person was not well, and I know that he was not dangerous. Would I have crossed the street if I saw someone gushing blood? Certainly not. It’s a lot easier to know what to do in such cases. It’s an acute problem that can be easily “fixed.” A makeshift tourniquet and a call to 911 are things I can organize that would have the potential to be helpful. In contrast, for someone experiencing psychotic symptoms, it’s generally not so clear what we can do in that moment that will make a difference. On the other side of the street ashamed and helpless – this is where many of us find ourselves when we love someone who has serious mental illness.
4. Is the person I avoided simply exercising his civil rights? People have civil rights that need to be honored, even when family members, friends and professionals might have other ideas about what is in someone’s best interest. Thus, like everyone else, people with serious mental illness have the right to refuse care, including medication, as long as they have the mental capacity to make such decisions and as long as there is not imminent danger to self or others. Exact definitions of mental capacity vary around the world, but essentially they all share the common principles of ability to understand information about a decision, remember this information, use this information to make a decision, or communicate a decision. We know that mental disorders act on the brain and impair brain function so assessment of “mental capacity” can be especially challenging in the case of serious mental illness.
5. So what can we do? In that moment, it may be true that there was little I could have done to address the underlying health condition that rendered this individual alone, homeless and so unwell. But I am perpetually troubled by the fact that people suffering with serious mental illnesses languish on the streets when we would not tolerate such lack of care for individuals with other serious health conditions. I know I am not alone.
Cost-effective, coordinated health care services and community programs for individuals with serious mental illness exist. Such programs contribute to healthier communities for all. We have a long way to go to get these programs disseminated. Our next step – individually and collectively- needs to be making the intentional choice to not cross the street.
