His Name Was Dominic
His name was Dominic.
I met Dominic many years ago when I was working in the mental health unit at St. Francis Hospital in Pittsburgh. It was nearing the Christmas holiday and Dominic had arrived at the Emergency Room and, according to the admission note, had reported that he felt like hurting himself or someone else.
When I met with Dominic to do my part of the intake assessment, I found a quiet, friendly, seemingly harmless, older man who quickly expressed an interest in the recreation programs that we offered as well as the upcoming Christmas party. "Wednesday night Bingo is my favorite."
Dominic, it turned out, had lived almost his whole life in one of the state psychiatric facilities outside of Pittsburgh. As a young man, Dominic had shown some issues with anger and rage, what was likely a learning disorder, and had started dabbling in some criminal activity.
In terms that are rarely used today, he was identified by the system as "incorrigible." His family, concerned for his safety, their safety and his mental health, had him committed to a short-term treatment facility such as St. Francis, from which he was eventually transferred to the state facility.
Dominic lived the next 40+ years of his life in that institution.
With the passing of legislation in the late 1960s and early 1970s in support of the civil rights of people with chronic mental health or developmental issues, the move toward community-based treatment for people with long-term issues resulted in the closing of the big state hospitals as well as those that were called "state schools."
Residents and patients of those large institutions were moved to community based programs, group homes, and, in rare cases, back to their families. The theory was that treating people in the community, nearer to family support and with greater opportunities for interaction with the mainstream, would be not only cheaper but more humane.
Unfortunately, for people like Dominic, there were problems with that plan. Without proper vocational training, community integration programs and a gradual easing back to the real world, to say nothing of the fact that families and relatives were either gone or no longer interested, residents of those big warehouses were often re-victimized by the system. Social skills developed over the decades in the hospital and other coping mechanisms needed to survive in an institution didn't translate well in the return to the community.
For Dominic, it meant timing a visit to the ER and saying the buzz words so that he could spend the holidays in a system and with people and staff with whom he felt comfortable. Throughout his stay, he was pleasant, compliant and didn't report any suicidal or homicidal thoughts or demonstrate any negative behaviors.
I remember at his discharge planning conference, Dominic asked if he could please go back to the state hospital. "I know what to expect there. I know the rules. I had friends and went to my job in the orchards every day there. We had parties and bingo and other activities." Dominic was willing to give up his independence so that he could also give up feeling alone.
I thought about Dominic this week when reading the story of the shooting at the hospital near Philadelphia. A patient arrived at his psychiatrist's office with his caseworker and an argument of some kind erupted. The patient ended up shooting and killing the 53 year old female caseworker who had accompanied him to the appointment.
The psychiatrist was able to reach his own weapon from a hiding place and ended up disabling the patient. The psychiatrist has been labeled a hero although questions about his compliance with "no weapons on grounds" will certainly be a topic of discussion moving forward. The patient survived the gunshot wounds and will soon be facing charges related to the incident.
A person with significant mental illness will eventually be housed in an institution to keep him and others safe. The question is – which institution?
With greater diagnostic tools, co-occurring addiction issues and a continued disengagement of people from other people in our overly stressed society, mental illness is on the rise. Depending on where you get your facts, statistics suggest a that we have seen a doubling, tripling or even quadrupling in the number of people with identified mental health issues in the recent decades.
In addition to lost work time, the stress on families and healthcare systems that are not equipped to handle the numbers and the related social consequences of criminal activity, homelessness, etc. addressing our mental health crisis is as much a priority as immigration or what's happening in the Middle East.
From a lunatic with a gun in a movie theatre in Colorado to the percentage of adults who are prescribed and taking anti-anxiety, anti-depression or anti-psychotic drugs to children being diagnosed as bi-polar, it's pretty clear that we are in the midst of a mental health epidemic.
For many of those with mental health problems, the result will be institutionalization but not of the kind that Dominic experienced. According to the Bureau of Justice statistics, over half of the prison population across the United States has identifiable mental health issues and significant psychiatric diagnoses.
In county and city jails, those numbers are believed to be greater than 50 percent. Corrections staff and budgets are ill-equipped to address the challenges of treating and managing people with mental health issues. Suicide, particularly in solitary confinement where many of these troubled folks are sent to keep them safe, is the leading cause of death in jails and in the top five causes of death in prisons.
We've traded one institution for another.
The difficulty in reforming how we treat individuals with mental illness comes from the need to balance individual rights with concerns for the greater safety of our community. A return to the days of involuntary commitments that evolve to 40 years stay in a human warehouse is certainly not the answer.
However, providing families, schools and communities with greater tools for identifying warning signs and, perhaps a re-tightening of the legislation and code that allows for forced evaluations is one place to start. Shifting government dollars away from some of the ridiculous programs and government waste that makes the news every day into support of treatment facilities, in-patient programs and community programs has to be a priority.
Giving family members and authorities the tools to get the right help for a person who is clearly in need must be developed with oversight to prevent abuses. Training those within the legal system to identify situations where mental health is the primary factor or causation of an issue would perhaps allow us to refer the person into the right system for help.
As we saw with the recent shooting and stabbing rampage in Santa Barbara, many of those who go on to harm others have clearly demonstrated problematic behavior and were either refused or released from treatment. To quote Richard Martinez, the father of victim Christopher Michael-Martinez, "not one more" should be our motivation for mental health reform.
De-stigmatizing mental health issues has to be part of the plan. We need to understand and acknowledge that mental illness is no more someone's fault than getting cancer.
I think about Dominic and Harry and Jane and Mary, some of the people who used to use the figurative revolving door at St. Francis and who I got to know during my time spent working in that system. They would come to the hospital for a recharge -- a return to the familiar -- and then we would send them on their way.
I remember Dominic looking over his shoulder as we wished him luck and sent him on his way at discharge. With a smile and a wave, he whispered back to me. "What month is the summer picnic this year?"