Let's Heal, Not Blame

The victims of sexually transmitted diseases and of severe mental illnesses need help, not punishment.

MANY OF OUR MOST COSTLY MALADIES result from health-endangering personal choices, including the choice of accepting or rejecting prevention and treatment regimes of proven efficacy. Sexually transmitted diseases belong to this group of illnesses. They cause deep personal pain to the patients and to those dearest to the patients and make costly public health and public safety demands. Society too often responds by blaming and punishing the patients for their illnesses.

Like STD, severe mental illnesses cause deep personal pain to the patients and to those dearest to the patients, and make costly public health and public safety demands. Again society too often holds the mentally ill patient responsible for the illness and skimps on prevention and treatment. Physicians strive for a neutral, non-judgmental stance in serving patients with STD or severe MI. We know that if we don't, we cannot possibly help.

Sacramento County's gonorrhea rate is more than twice the state's rate, 132 per 100,000 population in 1998, compared with 58 per 100,000. Sacramento's rate has risen 10 percent in one year, and has been disproportionately high for years. We need to know why and what we can do about it-without blaming the patient or the caregivers.

Sacramento's incidence of chlamydia rose at a rate 30 percent higher than the state's rise. Chlamydia and gonorrhea are highest among 15 to 19-year-olds. Why don't our mid-adolescents hear the message, or care? How must primary care physicians change what they do and say when they see adolescent patients? How can Sacramento's clinicians and health departments collaborate on case-finding and reporting, on treatment and follow-up, and on prevention? How can we help these adolescents and young adults make less dangerous choices? Certainly not by blaming them.

Severe mental illnesses, so often a result of a cruel interplay of congenital forces and the deprivations and assaults of life, may impair perception and judgment about life choices, including treatment. Again it is easy to blame the victim, but if we do we cannot help. If in protecting the community we disrespect the privacy and autonomy of the patient, we serve neither the patient nor the community well. Yet, if we let the patient continue to make self-destructive choices, we also serve neither the patient nor the community well.

The Lanterman-Petris-Short Act has sharply curtailed the commitment of mentally ill persons for the past 30 years. Administrative and court interpretations have further restricted the ability of physicians to treat seriously mentally ill patients involuntarily. In safeguarding the autonomy of the mentally ill, even when illness has stolen their capacity to give autonomous consent, we have left patients untreated, their families desperate, and the public fearing the sometimes dangerous mentally ill people who roam the streets. Meanwhile, law enforcement is swamped, trying to treat although their duty is to protect. Frustrated, society conspires to blame the victim for the illness.

Two new public policies about involuntary treatment deserve our attention. Assemblywoman Helen Thomson got LPS reform through last year's legislature, but lost it to a veto on the grounds it would be too expensive to implement. She is still working on reform and one of the people who is working with her tells us the story.

The other legislation is Assemblyman Darrell Steinberg's bill of last year, providing housing, treatment and management to homeless people identified as severely mentally ill and treatable. It was enacted and is now funding a Sacramento County program. Assemblyman Steinberg tells us his view of the problem and a solution.

Both legislators shun blaming anyone, least of all the patients. Instead they are trying to protect and serve patients and the public simultaneously. Complex social issues are involved and we must guard against over-using involuntary psychiatric treatment as much as we must stop under-using it. We can do that if we serve as non-judgmental physicians, dedicated to helping, not punishing.

Ed_Rudin@macnexus.org