At Issue: Freedom for the Irrational

By Richard Stengel

Ed Koch, New York City's voluble mayor, recently recounted how he had toured Manhattan in the company of some mental health experts. Concerned about the mentally ill who live on the streets, Hizzoner had decided to do some sidewalk research. On the tony Upper East Side, the group encountered a bedraggled, incoherent woman lying in the street, having thoroughly soiled herself. The woman could not be forcibly committed to a mental health institution, said the experts, because she did not present an "imminent danger." Koch was stunned, and recalled thinking, "You're loony yourself."

A normal, common-sense reaction, certainly, but one with uncertain and morally perplexing consequences. Koch has just announced that on Oct. 1 the city will begin the involuntary institutionalization of the homeless mentally ill who are incapable of caring for themselves. The new "self-neglect" rule, as one city official calls it, will loosen the current requirement that the potential patient be an immediate danger to himself or others. This tough standard is common around the U.S. To be accepted in crowded mental health facilities nowadays, says Jill Halverson, a Los Angeles activist, "a homeless person has to be either killing himself in front of the admitting doctor or trying to kill the admitting doctor."

Koch's plan reflects a needed sense of realism, in the view of conservatives as well as many liberals. In more than a dozen states, officials have been inching in a similar direction. But in a country that speaks in the same breath of the right to liberty and the right to life, this new approach raises old, complicated questions. How much deviation in behavior ought a free society tolerate? Is it rational to enshrine the liberty of those so irrational they cannot understand the nature of their rights? Is it not more humane -- indeed, is it not morally required -- to come to the aid of people who are suffering, no matter their resistance?

These questions arise after nearly 30 years of what has come to be called deinstitutionalization. In the mid-1950s the widespread use and effectiveness of the antipsychotic drug Thorazine allowed the denizens of "insane asylums" to be treated outside the hospital where, all agreed, they were better off. The policy satisfied the civil-libertarian instincts of mental health advocates, while conservatives counted up the tax dollars saved. But an optimistically promised second stage of deinstitutionalization was not so easy to deliver: follow-up care in the community frequently failed to materialize. The number of mental patients in U.S. institutions did shrink, though, from a peak of 560,000 in 1955 to some 146,000 in 1984. In New York, the number declined from 93,000 in 1955 to about 20,000 today. One-fifth to one-third of America's homeless are now considered mentally ill.

Deinstitutionalization fit perfectly into the antiauthoritarian zeitgeist of the '60s and early '70s. Radical Psychiatrist R.D. Laing popularized the rather romantic notion that insanity could be a sane reaction to an insane world, while Sociologist Erving Goffman suggested that institutions, by their very nature, stifled individual development. Courts began to protect the rights of the mentally ill against the encroachments of the state. But in the 1980s, the continual seesaw in America between individual freedom and society's responsibility is tipping again.

"Things have swung too far," says Merna McMillan, director of health care and mental health services in Santa Barbara County, Calif., who backed Santa Barbara's decision last year to allow the homeless to sleep in some public places. "I don't think that's what civil liberties are about, to live like that, to be free to be mentally ill." The problem has some social workers sounding like police who complain about criminal rights. "We are tired of being handcuffed by these issues," says Jackie Edens, who spent 8 1/2 years as a Chicago crisis-intervention worker.

Robert Levy, an attorney who follows mental health issues for the New York Civil Liberties Union, is concerned that the new Koch plan could be used "to rid society of people who are unpleasant to look at." City officials reply that anyone picked up must be diagnosed on the street by "mobile psychiatric teams," then must be rediagnosed twice in the hospital within two days; the patient, who can only be kept for a maximum of 30 days, has the right to a free lawyer and a court hearing within five days. Even assuming such safeguards would help, Levy and other homeless advocates see a continuation of the "illusion of care" -- civic cosmetics as phony as the fake Cartier watches hawked on Manhattan street corners. "We have these academic debates about the propriety of forced treatment and commitment of people," says Robert Hayes of the National Coalition for the Homeless, "but they mean nothing. The real issue is that there are no beds and no dollars. The problem is not an abundance of civil liberties for the homeless; it is a scarcity of beds."

Once invisibly warehoused, now sidestepped on sidewalks, the mentally ill are defenseless prey to the pendulum's swing. Says the Rev. Alice Callaghan, who for 15 years has run homeless centers in Los Angeles: "We've just been ricocheting between unacceptable answers." The better way, she and most experts believe, is smaller group homes with government-backed support. But communities, as well as the federal and state governments, have to be willing to accept such homes, and pay the bill. "That," argues Kevin Limbeck, executive director of Chicago's Coalition for the Homeless, "is the real ethical solution."

With reporting by Wayne Svoboda/New York