Wow. I understand the problems you mention in institutional care, whether of the mentally retarded or the severely mentally ill. What state are you referring to?

People who are simply mentally retarded are not usually "violent" or abusive to others; however, there are some folks who have multiple problems (often called "dually diagnosed") or have behavior problems in addition to their mental retardation or developmental disability. It seems logical when you think about it: Even "normal" people come in a variety of personalities, mentally disabled people may have brain-defect reasons for things like aggression, poor judgement, or impulsivity, and it must be extremely frustrating to live life as a severely disabled person.

I am a very strong advocate for three things relevant to your comments: caregiver safety, proper care, and access to & encouragement for appropriate residential settings.

(1) Caregivers' safety. Caregivers who are following the rules and trying to do a good job deserve extensive protection from injury or abuse. Those who are injured because of ill-conceived agency limitations on their safety should, in my view, be talking to their lawyers, union leaders, and legislators.

(2) Proper medical and psychological care for patients/residents. Misunderstanding or misapplication of many of the "rights" you describe actually keep lots of patients and residents from getting better. I've had a lot of experience with this (e.g., as former medical director for a large state department of mental health and mental retardation). Of course people's rights and preventing abuse are important, but those concepts are sometimes stretched to an unhealthily politically-correct extent, usually by people who don't understand the issues and/or are more interested in media coverage than good, individualized care. I have seen, literally, more than one patient "die with her rights on" because a consumer organization (such as a federally-funded protection & advocacy organization which is supposed to work for patients' interests) or a pseudoscientific group blocked necessary care.

Readers of this forum can help by loudly advocating for patients' rights to good care, not just the "right" of mentally disabled patients to "choose" to be left alone by clinicians, and thus to suffer when help is otherwise easily available.

(3) Easy access to care and social encouragement for residential settings/care. Two things -- the misunderstood "rights" mentioned above and state & local financing for the mentally disabled -- prevent many people from getting hospital, institutional, or intensive community care. A shocking number of mentally disabled people who could be helped, or at least safely maintained in humane surroundings, are allowed to suffer (and sometimes die) without such help.

The decades-old idea that hospitals & institutions are bad places, or places of last resort, is simply untrue for hundreds of thousands of mentally disabled people. Of course unwarranted hospitalization is a bad idea, but that's not what I'm talking about. In the over 4 decades since the so-called deinstitutionalization movement began, we should have learned that it only works if (a) the community provides adequate clinical and social supports and (b) the community understands that deinstitutionalization doesn't work for everyone. I can't think of a single state or community in the U.S. that routinely provides acceptable intensive community care for patients who need it, appropriate lengths of hospital stay for patients who need inpatient care, and protected residential settings for people who need something in between hospitals and community supports in order to live reasonable lives.

That's my rant for the day. It's not limited to the forensic pateints referred to in the title of this thread; the issue is far larger.

If readers want to hear more, and/or get in on the beginning of a movement my wife and I call "Real Help," they are welcome to send an email to me at reidw@reidpsychiatry.com (type the words "Real Help" in the subject line).

Thanks,
William H. Reid, M.D.