Psychiatric Rehabilitation Journal 2014, Vol. 37, No. 1, 68 –70
© 2014 American Psychological Association 1095-158X/14/$12.00 DOI: 10.1037/prj0000053
SPEAKING OUT
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Life, Liberty, and the Pursuit of Happiness: Reframing Inequities Experienced by People With Severe Mental Illness Rob Whitley
Benjamin F. Henwood
McGill University and Dartmouth College
University of Southern California, Los Angeles
Topic: In the Declaration of Independence, Thomas Jefferson stated that citizens of the new republic had fundamental and inalienable rights to “life, liberty and the pursuit of happiness.” Purpose: The purpose of this article is to reframe inequities experienced by people living with severe mental illnesses in terms of violations of Jeffersonian rights to “life, liberty and the pursuit of happiness.” We simultaneously consider governmental and clinical efforts to address identified inequities and uphold these rights. Sources Used: The broad research literature on severe mental illnesses was examined. Conclusions and Implications for Practice: People with severe mental illnesses experience numerous inequities regarding “life, liberty and the pursuit of happiness.” These inequities include diminished life expectancy, excessive involuntary commitment and elevated rates of unemployment and homelessness. Governmental and clinical responses to such inequities include the Affordable Care Act and the Olmstead Decision, as well as recovery-oriented interventions such as Supported Employment and Supported Housing. Keywords: severe mental illness, rights, discrimination, mental health services, inequities
engage the public in supporting measures that improve life for people who live with severe mental illnesses.
In the Declaration of Independence, Thomas Jefferson famously stated that citizens of the new republic had fundamental and inalienable rights to “life, liberty and the pursuit of happiness.” These words have resonated with Americans and others ever since, neatly summarizing the spirit of a just society where individuals are free to fulfil their full potential. As time has progressed the lofty ideals expressed in these founding documents have been interpreted as applicable to all citizens of the republic. Successive amendments to the constitution have specifically noted that these rights cannot be denied on account of “race, color” (Amendment XV) and “sex” (Amendment XIX), though as yet there is no particular amendment applying to people with disabilities. Instead, there have been widespread governmental initiatives to uphold Jeffersonian rights for people with disabilities, most notably the 1990 Americans with Disabilities Act (ADA). In this article, we reframe the inequities experienced by people living with severe mental illnesses in terms of violations of Jeffersonian rights to “life, liberty and the pursuit of happiness.” We simultaneously consider governmental and clinical efforts to uphold these rights. We argue that this Jeffersonian approach, based on deeply held and culturally resonant values, might better
Life Evidence suggests that the right to life, in its most basic definition, has been violated for people living with a severe mental illness. Research has shown that they have significantly reduced life expectancies, as well as standardized mortality rates significantly higher than the general population (Saha, Chant & McGrath, 2007; Laursen, 2011). This has been imputed to various factors including poor diet, substance abuse, lack of exercise, and smoking. This leads to a large burden of disease including diabetes, hepatic disease, and cancer. Other factors that affect their longevity include the iatrogenic effects of psychiatric medication, and elevated rates of injury, accident, and suicide. The Patient Protection and Affordable Care Act (ACA) is a step in the right direction, promoting the integration of physical and mental health care. Still, quality health care is necessary but not sufficient to reduce these health disparities. More is needed to address the social determinants of health in people with severe mental illness. Indeed, much research suggests that people with severe mental illnesses experience a low quality of life, often living in circumstances of poverty, discrimination, and poorly funded public mental health services. This could be addressed by various measures. These include concerted social action, better provision of physical and mental public health services, increased availability of evidence-based practices, and interventions that encourage healthy behaviors.
Rob Whitley, Douglas Mental Health University Institute, McGill University, Montreal, Canada, and Dartmouth Psychiatric Research Center, Dartmouth College; and Benjamin F. Henwood, School of Social Work, University of Southern California, Los Angeles. Correspondence concerning this article should be addressed to Rob Whitley, Department of Psychiatry, McGill University, Montreal, Canada. E-mail: [email protected] 68
LIFE, LIBERTY, AND THE PURSUIT OF HAPPINESS
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Liberty The liberty of people with severe mental illnesses has also been unduly infringed upon both by their overrepresentation in the jail and prison population and in continued widespread use of involuntary psychiatric institutionalization. The disproportionately high rates of people with severe mental illness in the jail and prison populations is often due to misdemeanors or factors associated with untreated mental illness (Diamond, Wang, Holzer et al., 2001). This indicates the importance of early intervention programs and jail diversion services that can reduce incarceration. It also implies that judges should have more discretionary power so that rigidity in the legal system such as “three strikes and you’re out” policies do not unduly discriminate against people with severe mental illnesses. Involuntary commitment and psychiatric institutionalization— which remains common throughout the world—is also an obvious way in which the liberty of people with severe mental illnesses is violated. In response, the U.S. Supreme Court’s 1999 Olmstead decision upheld the right of people with mental disabilities to live in the community, demanding an end to unnecessary segregation in institutional settings. The Department of Justice, backed both by the ADA and the Olmstead decision, is now working to ensure that states enact this right in practice. Some attempts to reduce involuntary inpatient commitment have resulted in the introduction of involuntary outpatient commitment, also known as community treatment orders. These allow patients to maintain community tenure on the condition they engage with certain treatments. The extent to which outpatient commitments infringe upon, or support, an individual’s liberty is currently an area of debate, though most commentators agree that community treatment orders are preferable (from a human rights perspective) to involuntary inpatient treatment (Appelbaum, 2005). Whichever, some evidence suggests that involuntary commitment of either type is overused, and that it is often an unsatisfactory default option due to the absence of supportive community services (McGarvey, Leon-Verdin, Wanchek et al., 2013). As such, comprehensive service provision may prevent the need for costly involuntary commitment, thus preserving the liberty of people living with severe mental illnesses.
Pursuit of Happiness There are various routes to happiness, many of which are culturally mediated. In most Western societies, happiness often derives from factors such as rewarding employment, a settled domestic life, community involvement, and the pursuance of hobbies and interests. Unfortunately, many of these factors are systematically denied to people living with severe mental illnesses. For example, research suggests that homelessness is a frequent corollary of severe mental illness, with over 35% of the homeless population having such an illness (Hopper, Jost, Hay et al., 1997). Likewise, it is estimated that around 80% of people living with severe mental illnesses are unemployed, even though approximately 70% express a desire to work (Becker & Drake, 2003). Being homeless and unemployed are obviously serious impediments to the pursuit of happiness. Meaningful action, such as the provision of supportive housing and supported employment services, can reduce inequalities in housing and employment (Becker & Drake, 2003; Rog, 2004). Satisfying the basic desire for a home
69
and a job can give people living with severe mental illnesses the physical, financial and ontological security to then pursue a family life, hobbies, and interests. Stigma and discrimination are also key issues that influence the pursuit of happiness. Such discrimination can occur in the search for employment or housing, though this can be challenged through the ADA. Other forms of stigma are less amenable to legal challenge and require a shift in wider public attitudes. For example, stigma can inhibit the formation and maintenance of friendships, romantic relationships and familial relations. Internal (or “felt”) stigma can also constrain the desire among people living with severe mental illnesses to become involved in community organizations such as churches or sports clubs, which in fact may not always be welcoming to people who disclose a severe mental illness (Thornicroft, 2006). Antistigma campaigns could thus be seen as essential to the pursuit of happiness inasmuch as they create favorable societal conditions in which people living with severe mental illnesses can flourish. Research suggests that local and targeted educational campaigns, aimed at key groups such as employers, police chiefs, teachers, and journalists, can diminish stigma and ensure that influential segments of society understand the realities of life with a severe mental illness (Pinfold, Thornicroft, Huxley et al., 2005). Fortunately, important efforts are occurring in some states such as the antistigma initiative of the California Mental Health Services Authority that is currently funding numerous grassroots antistigma projects focusing on targeted populations. These efforts could be replicated elsewhere, ensuring that local communities are primed to facilitate the pursuit of happiness for individuals who experience a severe mental illness.
Conclusion Jeffersonian rights are deeply held and culturally resonant values that are considered the basic building blocks of a fair society. These rights indubitably apply to people with severe mental illnesses, which has largely been recognized by government initiatives including the ADA, ACA, and Olmstead decision. Perhaps the most recognizable governmental initiative in the recent history of human rights for people with severe mental illnesses is the 2003 President’s New Freedom Commission, which declared that mental health services must focus on recovery, (holistically defined) rather than simple symptom management. This set in motion the transformation of many public mental health systems to provide better services, though many other systems continue to fall short of “achieving the promise.” Furthermore, though the commission’s report marked the highest endorsement of recovery and human rights for people with severe mental illnesses within the federal government, it did not necessarily change public discourse and attitudes. Although top-down governmental endorsement of the rights of individuals with severe mental illnesses is essential, bottom-up support from the public at large is equally important. We argue that the concepts of “life, liberty and the pursuit of happiness” provide an understandable framework to the lay public and to key policymakers about problems faced by people with severe mental illnesses. This may be a more effective way of directing public discourse and engendering public support than the deployment of complex statistics or abstract academic arguments.
WHITLEY AND HENWOOD
70
Americans are rightly proud of the principles enshrined in the documents formulated by the founding fathers. These documents outline ideals for a civilized and enlightened society. As such, we must all strive to ensure that “life, liberty and the pursuit of happiness” become realities, rather than ideals, for people who live with a severe mental illness.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
References Appelbaum, P. S. (2005). Assessing Kendra’s Law: Five years of outpatient commitment in New York. Psychiatric Services, 56, 791–792. doi:10.1176/appi.ps.56.7.791 Becker, D., & Drake, R. (2003). A working life for people with severe mental illness. Oxford, UK: Oxford University Press. doi:10.1093/ acprof:oso/9780195131215.001.0001 Diamond, P. M., Wang, E. W., Holzer III, C. E., & Thomas, C. (2001). The prevalence of mental illness in prison. Administration and Policy in Mental Health and Mental Health Services Research, 29, 21– 40. doi: 10.1023/A:1013164814732 Hopper, K., Jost, J., Hay, T., & Welber, S. (1997). Homelessness, severe mental illness, and the institutional circuit. Psychiatric Services, 48, 659 – 665.
Laursen, T. M. (2011). Life expectancy among persons with schizophrenia or bipolar affective disorder. Schizophrenia Research, 131, 101–104. doi:10.1016/j.schres.2011.06.008 McGarvey, E. L., Leon-Verdin, M., Wanchek, T. N., & Bonnie, R. J. (2013). Decisions to initiate involuntary commitment: The role of intensive community services and other factors. Psychiatric Services, 64, 120 –126. doi:10.1176/appi.ps.000692012 Pinfold, V., Thornicroft, G., Huxley, P., & Farmer, P. (2005). Active ingredients in anti-stigma programmes in mental health. International Review of Psychiatry, 17, 123–131. doi:10.1080/09540260500073638 Rog, D. J. (2004). The evidence on supported housing. Psychiatric Rehabilitation Journal, 27, 334 –344. doi:10.2975/27.2004.334.344 Saha, S., Chant, D., & McGrath, J. (2007). A systematic review of mortality in schizophrenia: Is the differential mortality gap worsening over time? Archives of General Psychiatry, 64, 1123–1131. doi:10.1001/ archpsyc.64.10.1123 Thornicroft, G. (2006). Shunned: Discrimination against people with mental illness. Oxford, UK: Oxford University Press.
Received October 24, 2013 Revision received January 16, 2014 Accepted January 16, 2014 䡲
Copyright of Psychiatric Rehabilitation Journal is the property of American Psychological Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
© 2014 American Psychological Association 1095-158X/14/$12.00 DOI: 10.1037/prj0000053
SPEAKING OUT
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Life, Liberty, and the Pursuit of Happiness: Reframing Inequities Experienced by People With Severe Mental Illness Rob Whitley
Benjamin F. Henwood
McGill University and Dartmouth College
University of Southern California, Los Angeles
Topic: In the Declaration of Independence, Thomas Jefferson stated that citizens of the new republic had fundamental and inalienable rights to “life, liberty and the pursuit of happiness.” Purpose: The purpose of this article is to reframe inequities experienced by people living with severe mental illnesses in terms of violations of Jeffersonian rights to “life, liberty and the pursuit of happiness.” We simultaneously consider governmental and clinical efforts to address identified inequities and uphold these rights. Sources Used: The broad research literature on severe mental illnesses was examined. Conclusions and Implications for Practice: People with severe mental illnesses experience numerous inequities regarding “life, liberty and the pursuit of happiness.” These inequities include diminished life expectancy, excessive involuntary commitment and elevated rates of unemployment and homelessness. Governmental and clinical responses to such inequities include the Affordable Care Act and the Olmstead Decision, as well as recovery-oriented interventions such as Supported Employment and Supported Housing. Keywords: severe mental illness, rights, discrimination, mental health services, inequities
engage the public in supporting measures that improve life for people who live with severe mental illnesses.
In the Declaration of Independence, Thomas Jefferson famously stated that citizens of the new republic had fundamental and inalienable rights to “life, liberty and the pursuit of happiness.” These words have resonated with Americans and others ever since, neatly summarizing the spirit of a just society where individuals are free to fulfil their full potential. As time has progressed the lofty ideals expressed in these founding documents have been interpreted as applicable to all citizens of the republic. Successive amendments to the constitution have specifically noted that these rights cannot be denied on account of “race, color” (Amendment XV) and “sex” (Amendment XIX), though as yet there is no particular amendment applying to people with disabilities. Instead, there have been widespread governmental initiatives to uphold Jeffersonian rights for people with disabilities, most notably the 1990 Americans with Disabilities Act (ADA). In this article, we reframe the inequities experienced by people living with severe mental illnesses in terms of violations of Jeffersonian rights to “life, liberty and the pursuit of happiness.” We simultaneously consider governmental and clinical efforts to uphold these rights. We argue that this Jeffersonian approach, based on deeply held and culturally resonant values, might better
Life Evidence suggests that the right to life, in its most basic definition, has been violated for people living with a severe mental illness. Research has shown that they have significantly reduced life expectancies, as well as standardized mortality rates significantly higher than the general population (Saha, Chant & McGrath, 2007; Laursen, 2011). This has been imputed to various factors including poor diet, substance abuse, lack of exercise, and smoking. This leads to a large burden of disease including diabetes, hepatic disease, and cancer. Other factors that affect their longevity include the iatrogenic effects of psychiatric medication, and elevated rates of injury, accident, and suicide. The Patient Protection and Affordable Care Act (ACA) is a step in the right direction, promoting the integration of physical and mental health care. Still, quality health care is necessary but not sufficient to reduce these health disparities. More is needed to address the social determinants of health in people with severe mental illness. Indeed, much research suggests that people with severe mental illnesses experience a low quality of life, often living in circumstances of poverty, discrimination, and poorly funded public mental health services. This could be addressed by various measures. These include concerted social action, better provision of physical and mental public health services, increased availability of evidence-based practices, and interventions that encourage healthy behaviors.
Rob Whitley, Douglas Mental Health University Institute, McGill University, Montreal, Canada, and Dartmouth Psychiatric Research Center, Dartmouth College; and Benjamin F. Henwood, School of Social Work, University of Southern California, Los Angeles. Correspondence concerning this article should be addressed to Rob Whitley, Department of Psychiatry, McGill University, Montreal, Canada. E-mail: [email protected] 68
LIFE, LIBERTY, AND THE PURSUIT OF HAPPINESS
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Liberty The liberty of people with severe mental illnesses has also been unduly infringed upon both by their overrepresentation in the jail and prison population and in continued widespread use of involuntary psychiatric institutionalization. The disproportionately high rates of people with severe mental illness in the jail and prison populations is often due to misdemeanors or factors associated with untreated mental illness (Diamond, Wang, Holzer et al., 2001). This indicates the importance of early intervention programs and jail diversion services that can reduce incarceration. It also implies that judges should have more discretionary power so that rigidity in the legal system such as “three strikes and you’re out” policies do not unduly discriminate against people with severe mental illnesses. Involuntary commitment and psychiatric institutionalization— which remains common throughout the world—is also an obvious way in which the liberty of people with severe mental illnesses is violated. In response, the U.S. Supreme Court’s 1999 Olmstead decision upheld the right of people with mental disabilities to live in the community, demanding an end to unnecessary segregation in institutional settings. The Department of Justice, backed both by the ADA and the Olmstead decision, is now working to ensure that states enact this right in practice. Some attempts to reduce involuntary inpatient commitment have resulted in the introduction of involuntary outpatient commitment, also known as community treatment orders. These allow patients to maintain community tenure on the condition they engage with certain treatments. The extent to which outpatient commitments infringe upon, or support, an individual’s liberty is currently an area of debate, though most commentators agree that community treatment orders are preferable (from a human rights perspective) to involuntary inpatient treatment (Appelbaum, 2005). Whichever, some evidence suggests that involuntary commitment of either type is overused, and that it is often an unsatisfactory default option due to the absence of supportive community services (McGarvey, Leon-Verdin, Wanchek et al., 2013). As such, comprehensive service provision may prevent the need for costly involuntary commitment, thus preserving the liberty of people living with severe mental illnesses.
Pursuit of Happiness There are various routes to happiness, many of which are culturally mediated. In most Western societies, happiness often derives from factors such as rewarding employment, a settled domestic life, community involvement, and the pursuance of hobbies and interests. Unfortunately, many of these factors are systematically denied to people living with severe mental illnesses. For example, research suggests that homelessness is a frequent corollary of severe mental illness, with over 35% of the homeless population having such an illness (Hopper, Jost, Hay et al., 1997). Likewise, it is estimated that around 80% of people living with severe mental illnesses are unemployed, even though approximately 70% express a desire to work (Becker & Drake, 2003). Being homeless and unemployed are obviously serious impediments to the pursuit of happiness. Meaningful action, such as the provision of supportive housing and supported employment services, can reduce inequalities in housing and employment (Becker & Drake, 2003; Rog, 2004). Satisfying the basic desire for a home
69
and a job can give people living with severe mental illnesses the physical, financial and ontological security to then pursue a family life, hobbies, and interests. Stigma and discrimination are also key issues that influence the pursuit of happiness. Such discrimination can occur in the search for employment or housing, though this can be challenged through the ADA. Other forms of stigma are less amenable to legal challenge and require a shift in wider public attitudes. For example, stigma can inhibit the formation and maintenance of friendships, romantic relationships and familial relations. Internal (or “felt”) stigma can also constrain the desire among people living with severe mental illnesses to become involved in community organizations such as churches or sports clubs, which in fact may not always be welcoming to people who disclose a severe mental illness (Thornicroft, 2006). Antistigma campaigns could thus be seen as essential to the pursuit of happiness inasmuch as they create favorable societal conditions in which people living with severe mental illnesses can flourish. Research suggests that local and targeted educational campaigns, aimed at key groups such as employers, police chiefs, teachers, and journalists, can diminish stigma and ensure that influential segments of society understand the realities of life with a severe mental illness (Pinfold, Thornicroft, Huxley et al., 2005). Fortunately, important efforts are occurring in some states such as the antistigma initiative of the California Mental Health Services Authority that is currently funding numerous grassroots antistigma projects focusing on targeted populations. These efforts could be replicated elsewhere, ensuring that local communities are primed to facilitate the pursuit of happiness for individuals who experience a severe mental illness.
Conclusion Jeffersonian rights are deeply held and culturally resonant values that are considered the basic building blocks of a fair society. These rights indubitably apply to people with severe mental illnesses, which has largely been recognized by government initiatives including the ADA, ACA, and Olmstead decision. Perhaps the most recognizable governmental initiative in the recent history of human rights for people with severe mental illnesses is the 2003 President’s New Freedom Commission, which declared that mental health services must focus on recovery, (holistically defined) rather than simple symptom management. This set in motion the transformation of many public mental health systems to provide better services, though many other systems continue to fall short of “achieving the promise.” Furthermore, though the commission’s report marked the highest endorsement of recovery and human rights for people with severe mental illnesses within the federal government, it did not necessarily change public discourse and attitudes. Although top-down governmental endorsement of the rights of individuals with severe mental illnesses is essential, bottom-up support from the public at large is equally important. We argue that the concepts of “life, liberty and the pursuit of happiness” provide an understandable framework to the lay public and to key policymakers about problems faced by people with severe mental illnesses. This may be a more effective way of directing public discourse and engendering public support than the deployment of complex statistics or abstract academic arguments.
WHITLEY AND HENWOOD
70
Americans are rightly proud of the principles enshrined in the documents formulated by the founding fathers. These documents outline ideals for a civilized and enlightened society. As such, we must all strive to ensure that “life, liberty and the pursuit of happiness” become realities, rather than ideals, for people who live with a severe mental illness.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
References Appelbaum, P. S. (2005). Assessing Kendra’s Law: Five years of outpatient commitment in New York. Psychiatric Services, 56, 791–792. doi:10.1176/appi.ps.56.7.791 Becker, D., & Drake, R. (2003). A working life for people with severe mental illness. Oxford, UK: Oxford University Press. doi:10.1093/ acprof:oso/9780195131215.001.0001 Diamond, P. M., Wang, E. W., Holzer III, C. E., & Thomas, C. (2001). The prevalence of mental illness in prison. Administration and Policy in Mental Health and Mental Health Services Research, 29, 21– 40. doi: 10.1023/A:1013164814732 Hopper, K., Jost, J., Hay, T., & Welber, S. (1997). Homelessness, severe mental illness, and the institutional circuit. Psychiatric Services, 48, 659 – 665.
Laursen, T. M. (2011). Life expectancy among persons with schizophrenia or bipolar affective disorder. Schizophrenia Research, 131, 101–104. doi:10.1016/j.schres.2011.06.008 McGarvey, E. L., Leon-Verdin, M., Wanchek, T. N., & Bonnie, R. J. (2013). Decisions to initiate involuntary commitment: The role of intensive community services and other factors. Psychiatric Services, 64, 120 –126. doi:10.1176/appi.ps.000692012 Pinfold, V., Thornicroft, G., Huxley, P., & Farmer, P. (2005). Active ingredients in anti-stigma programmes in mental health. International Review of Psychiatry, 17, 123–131. doi:10.1080/09540260500073638 Rog, D. J. (2004). The evidence on supported housing. Psychiatric Rehabilitation Journal, 27, 334 –344. doi:10.2975/27.2004.334.344 Saha, S., Chant, D., & McGrath, J. (2007). A systematic review of mortality in schizophrenia: Is the differential mortality gap worsening over time? Archives of General Psychiatry, 64, 1123–1131. doi:10.1001/ archpsyc.64.10.1123 Thornicroft, G. (2006). Shunned: Discrimination against people with mental illness. Oxford, UK: Oxford University Press.
Received October 24, 2013 Revision received January 16, 2014 Accepted January 16, 2014 䡲
Copyright of Psychiatric Rehabilitation Journal is the property of American Psychological Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
