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The Crumbleys, Part II

The school shooting in Michigan last week has opened up new avenues for thought and action, and re-opened old ones. We must not let this awful opportunity evaporate.

More than a week after the Oxford High School shootings in Michigan, the episode still bristles with implications that drain the will and resources of mental-health advocates. Granted, we are not (yet) nearly as overwhelmed as, say, hospital staffers in the resurgent Covid plague, though there is some psychic overlap.

School shootings have haunted our collective consciousness for decades—a hoary specter that still grips us with dread—but this case brings new horrors to consider. It was not just any old spree of classroom murders carried out by a mid-adolescent with a semiautomatic handgun bought for him as a Christmas present by his Dad on Black Friday. This one dropped some new elements on us—and managed to bypass an element of omission. Advocates and all people of conscience must grapple with them, no matter the tedium and the elusiveness of solutions. Our sanity as a nation is at stake.

So, what must we grapple with?

First, a recap: the 15-year-old shooter, Ethan Crumbley, faces 24 felony charges for slaughtering four classmates and wounding seven other people with that semiautomatic handgun lying around in his parents’ bedroom. The charges include first-degree murder and terrorism. Ethan was captured before he could turn his Christmas present on himself. This is relatively rare, as is the high count of charges. The terrorism count may be unprecedented, and might set a legal precedent. Or it might set a legal obfuscation: The Oakland County Prosecutor Karen McDonald told CNN, last week:

“There is no playbook about how to prosecute a school shooting and candidly, I wish . . . it didn’t occur so I wouldn’t have to consider it, but when we sat down, I wanted to make sure all of the victims were represented in the charges that we filed against this individual . . . If that’s not terrorism, I don’t know what is.”

Well, with all respect, Ms. McDonald, it might be mental illness. More on that in a moment.

The most striking new element is that the boy’s father and mother, James and Jennifer Crumbley, have been charged with four counts of involuntary manslaughter. This fact turns the spotlight on the criminal culpability of parents who leave lethal weapons unconcealed and unlocked in the household. Its implications could be seminal. The Crumbleys, as media accounts have made clear, are appalling and stupefyingly negligent parents. There’s a lot of that going around.

Here the “element of omission” takes center stage. Are the Crumbleys psychotic? Is Ethan psychotic? What is “psychotic”? How do we identify psychosis, and what do we do about it when we think we’ve seen it at work? Is this case an example of “shared psychosis,” in which some of the victims do not show clinical symptoms? What are the responsibilities—and the risks—of intervening in the actions of one who might be in a psychotic state?

These are old, wearying questions. They have been charged with fresh urgency by the bloody Oxford affair. Or should have been. After days of online searching, I have not been able to find an indication that any of the Crumbleys has received psychiatric diagnosis. I’ve found nothing but the most glancing speculation that serious mental illness—genetically inherited brain disease—was present in any of these people. And I certainly have found no serious, informed discussion about this possibility. And so the Crumbley story remains a missed opportunity at least as a “teachable moment,” a broad, ongoing national discussion on the nature of this beast. And on the policies—judicial/legal, educational, budgetary, and ethical—that scream out for rapid and thoroughgoing reform.

I am going to offer an example of policy dysfunction that I published in my previous blog. It was articulated by D.J. Jaffee, a disciple of the pioneering E. Fuller Torrey, who founded the invaluable Treatment Advocacy Center. Shortly before his death last year, Jaffe restated an observation he’d made many times in his talks and writings. It bears strongly on the Crumbley case:

“The law says we can’t do anything until after the psychotic victim becomes dangerous to self or others. As ludicrous as it sounds, the law requires dangerous behavior rather than prevents it.”

Credit: Database Center for Life CC BY-SA 2.1 JP via Wikimedia Commons

I cannot say whether Ethan Crumbley or his parents are mentally ill. A competent psychiatrist should and must make that call. I will say that telltale signs are blinking red.

There are Ethan’s notebook jottings, noticed by teachers: “The thoughts won’t stop. Help me,” and “Blood everywhere,” and “my life is useless,” and “the world is dead.” There are his sketches depicting a bullet and a bullet-riddled body.

There is the now-infamous message texted by Jennifer Crumbley to her son the day before he shot up Oxford High School, after a teacher told her that Ethan was searching for ammunition online in class: “LOL I’m not mad at you. You have to learn not to get caught.” And of course there is the fact of James buying that hideous weapon for his young son in the first place.

And there is the widely accepted thesis that if the rare onset of schizophrenia is going to occur, it typically occurs in mid-adolescence, Ethan’s period of life. This is the stage in which the prefrontal cortex is pruning itself of outworn synapses and generating new ones. If a genetic disorder produces over-pruning, an oversupply of normally essential chemicals such as dopamine can rush in and produce an imbalance that permanently damages the brain. (No thesis is yet seen as conclusive in the study of this affliction.)

Jurgitta, CC BY-SA 4.0 https://creativecommons.org/licenses/by-sa/4.0, via Wikimedia Commons

The social effects of serious mental illness spread out in a widening cone from the victim through the family, the community, our schools, our political life, and the health of the nation. Mass shootings continue to be rare, but the debilitating dread of mass shootings is nearly pandemic. The cumulative costs are as under-appreciated by the populace as the nature of the disease itself. Ignorance, apathy, and fear continue to rule.

I have called in the past for creation of a federal cabinet-level department that would unify, critique, and extend policymaking in all these problem areas as well as others. Foundational reform of our disgraceful jails and prison systems, de facto catch-basins for the insane, for instance. Solitary confinement, that turns sane prisoners into madpeople and the mad into vegetables, must be abolished.

D.J. Jaffe disagreed with me about this. He felt that such a department would only add another layer of bureaucracy.

All right. Let’s add another layer of bureaucracy.

Mental-health reform is borne on the backs, overwhelmingly, of women: mothers of victims, mostly. Their advocacy work in the past twenty years alone has been heroic and sporadically effective. But these “secular nuns”—the phrase just came to me—are largely worn out and disillusioned. They carry on, but we must not depend on them to keep doing the trench-work that the problem demands. Our advocates need reinforcement—collective national reinforcement. Society must be made safe from our Ethan Crumbleys. Yet we must not let things rest at primitive blame and punishment. Humanity and moral justice call us to protect the mentally ill and to reclaim them if we can. This would be the most honorable means of protecting ourselves, and reclaiming our own souls.

Marijuana and Psychosis: Real Data, Real Bad

via Christian Headlines

John Stonestreet, Roberto Rivera

The pitfalls and perils of marijuana legalization are well-documented. But whenever we discuss that research here on BreakPoint, we’re accused of not having the right research. What that means is that we’ve used studies that contradict the very vocal advocates of weed.

Well, let’s see what happens when we cite The British journal The Lancet, which, along with the New England Journal of Medicine and the Journal of the American Medical Association, is considered the “gold standard” for peer-reviewed medical research. It doesn’t get more “real” than being published in The Lancet.

A just-published study in The Lancet involving, among others, researchers at King’s College London, compared 900 people who had been treated for psychosis with 1,200 people who had not. Sample participants were drawn from across Europe and Brazil.

Both groups were surveyed on a host of factors, including their use of marijuana and other drugs. The study’s authors concluded that “people who smoked marijuana on a daily basis were three times more likely to be diagnosed with psychosis compared with people who never used the drug. For those who used high-potency marijuana daily, the risk jumped to nearly five times.”

By “high-potency” the researchers meant marijuana with a THC content of more than ten percent. To put that figure in context, a study of the weed seized by the DEA between 1995 and 2014 found the THC content went from about 4 percent in 1995 to 12 percent in 2014.

Today, it’s not uncommon to read of marijuana that’s legally-sold in places like Colorado with THC content above 20 percent, occasionally 30 percent! Legalization advocates minimize the exponential growth in potency by saying that twenty or more years ago, Americans didn’t have access to “the good stuff.”

Well, that misses the point by several astronomical units. The point is that those people who daily use “the good stuff” are five times more likely to find themselves in a hospital suffering from delusions and hallucinations, to name only two symptoms of psychosis.

Now, critics will respond, “That’s correlation, not causation.” And that’s the criticism leveled at journalist Alex Berenson, author of Tell Your Children: The Truth about Marijuana, Mental Illness and Violence, a book I recommend highly. But as I heard Berenson say just last week in Denver, of course it’s correlation and not causation. The only way to prove causation would be to ask half a sample group to experiment with something that may harm them. That’s not ethically possible. By the way, all the studies that made us believe that cigarette smoking causes lung cancer were correlated studies too, but that was enough to convince us all.

Even so, writer Ron Powers doesn’t need a peer-reviewed study to convince him of the link between marijuana use and psychosis. In his 2017 book, Nobody Cares About Crazy People, he tells the moving story of his two sons, Dean and Kevin, who were both diagnosed with schizophrenia in their late teens.

As Powers tells readers, while there is a strong genetic component to schizophrenia, there is no “schizophrenia gene.” Instead, it’s a constellation of genetic and environmental factors that make people susceptible to schizophrenia. One of these, as Powers painfully learned, is heavy marijuana use, especially in the teenage years.

Of course, some people will tell you that they and most people aren’t mentally ill, so there’s little if any risk. But for a host of reasons, no one can know that with certainty. In fact, all pronouncements about how safe marijuana legalization is simply overstates the case.

That’s exactly what happened here in Colorado. The possible pitfalls were denied or downplayed. And so, Colorado now holds the dubious distinction of leading the country in first-time drug use. And the rate of monthly marijuana use among 18-to-25-year-olds in states with legal weed is nearly three times as much as states that haven’t legalized it. By the way, 18-25 is the age when schizophrenia often begins to manifest.

And since legalization, Colorado has seen a a spike in marijuana-related emergency room visits by people between the ages of 13 and 20.

Given the well-documented mental health risks, especially to not-fully-formed adolescent brains, the rush to legalization is the height of irresponsibility. An irresponsibility that can shatter lives. And don’t just take our word for it.

BreakPoint is a Christian worldview ministry that seeks to build and resource a movement of Christians committed to living and defending Christian worldview in all areas of life. Begun byChuck Colson in 1991 as a daily radio broadcast, BreakPoint provides a Christian perspective on today’s news and trends via radio, interactive media, and print. Today BreakPoint commentaries, co-hosted by Eric Metaxas and John Stonestreet, air daily on more than 1,200 outlets with an estimated weekly listening audience of eight million people. Feel free to contact us at BreakPoint.org where you can read and search answers to common questions.

John Stonestreet, the host of The Point, a daily national radio program, provides thought-provoking commentaries on current events and life issues from a biblical worldview. John holds degrees from Trinity Evangelical Divinity School (IL) and Bryan College (TN), and is the co-author of Making Sense of Your World: A Biblical Worldview.

Publication date: March 27, 2019

Photo courtesy: Simone Scarano/Unsplash

Voices From the Sub-Universe

Today I introduce a new, occasional feature to my blog. Please see below:

Ron Powers

Voices from the Mental Illness Sub-Nation

Near the beginning of my recently published book about mental illness, “No One Cares About Crazy People,” I write: Too many of the mentally ill in our country live under conditions of atrocity.”

I grew convinced of this over the three years of my research into schizophrenia and its related brain afflictions that include schizoaffective disorder and extreme bipolarity. My examples in the book cover the spectrum of atrocity: mis-diagnoses (often “drug overdose”) by doctors; judges who order young victims into jail instead of treatment centers; beatings, deprivation of medications, and the torture of solitary confinement behind bars; death on the streets from bullets fired by untrained police; the daily fog and helplessness of the untreated insane.

These and some other areas—arenas—pretty much covered it, I was convinced. The spectrum of atrocity suffered by the mentally ill in America.

I was wrong.

I had limited my investigations to the barbarities visited on the “crazy people” themselves. Only after the book’s publication in March did a companion realm swim into focus for me: the realm of ordinary people whose lot is to care for the afflicted. These include mothers, fathers, siblings and friends of the helplessly impaired thousands whom our social bureaucracies have neglected and rejected and crushed. In many ways, these family members are damaged and abject as the loved ones they seek in vain to rescue.

No one cares, to coin a phrase, about those who care about crazy people.

This realm rushed at me in emails to my Facebook page and to the blog I created that related to the book. It swelled up within certain websites that I, as a writer about mental illness, was invited to join. These sites are closed off to anyone but relatives of madpeople; an enforced set of agreements keeps their conversations private unless they grant specific permission.

The writers on these sites are almost exclusively mothers—a fact that in itself merits contemplation. Mostly middle-class, they span several income, educational and racial categories. They are seldom “natural” writers, yet no one could mistake what they have to say. They write with the rare pitch of truth-telling passion that James Agee memorably described as “the cruel radiance of what is.”

What they have in common is a collective story more urgent, more morally devastating, more viscerally real, than be expressed by the modes by which outsiders receive information about mental healthcare: statistics and news items and policy statements and political press releases, delivered in detached, passionless prose.

Today, this blog commences an occasional compilation of these mothers’ voices (and those of other relatives as they are available). I have obtained permission from each source quoted, and have withheld identities, although some gave permission for that as well.

My hope here is twofold. One is that the reader will feel the same emotions as I have: shock and indignation that such chaos and neglect exist in America’s mental health-care systems, causing such a vast archipelago of misery and terror. The other is that these voices will encourage others to throw off fears of stigma and shame and begin hurling their own voices, their own testimonies, into the world. Only by putting human faces and voices upon the statistical morass of this ongoing atrocity can we hope to begin decisive, lasting reform.

We will begin with an example of the commonplace indifference and buck-passing at the community level that makes a mockery of the very phrase “mental healthcare system.”

“I have only enough strength this morning for a few lines. [My daughter] was discharged in 2011 with no psychiatric follow up appt. We scrambled to find someone, but before we could, she was readmitted to a second hospitalization. She had to drop out of school for a second time. She was too far behind. The [caregiver] had put her on a drug that literally made her bang her head on the wall. Then she was hospitalized another two weeks, and upon discharge the social worker made no referrals or linkages for her in the community, and would not respond to my inquiry about her diagnosis. I asked and her response was, ‘What does that matter?’

“She came home with us, and for the next two months, it was awful. In February, she was psychotic again, and ran out of the emergency room when I tried to get an evaluation. She was noncompliant with meds, and thought she was pregnant. She spent two weeks in one hospital and I threw a fit about her being sent home to us again because I had a 14-year-old at home to protect. She had become physically aggressive as well. They sent her to a state hospital after my totally pissing them off, and she stayed there for two months.

“My biggest frustration is no linkages, no follow-up, no support, etc. We were treated like nosy people wanting to meddle in our child’s life but, she was sent home to me to deal with every time. And, each and every time, I felt more inadequate to help her and to protect my other child. [Her sister] was terrorized and slept with her bedroom door locked. She also became angry with me, her mom, for not being able to protect her from her sister.”

Sometimes the afflicted family member is not a child, but a parent. Whether or not that parent has consented to treatment—and often they have not—the strain suffered by the spouse and children can be overwhelming. This eloquently written post offers an example:

“I must say that helping my kids to navigate their life in relation to their Daddy’s serious mental illness is serious emotional work. Tonight I held my 10 year old ‘Baby’ girl as she opened up and told me that sometimes she just starts feeling sad and then ALL of her sadness comes over her at once. I held her as she sobbed and sobbed. ‘Why can’t we have a normal family?’ ‘Why can’t we live in our own house where I could have my own room?’ ‘Why did my Daddy have to get sick?’ ‘Will it ever be okay?’ ‘Why can’t the doctors just fix this?”

“I want to know too.

“She voiced the little girl version of the questions that claw at my own heart and mind. The grief and loss come at us in waves. Tonight we sat and cried together. Her tears streaming down my chest and mine in her hair. . .”

The mother below and her son are casualties of grotesque, yet pervasive laws that place the “civil rights” interests of a person in psychosis above the right of a doctor or psychiatrist to order antipsychotic medication and/or involuntary commitment to a center for treatment. In most states, such a patient may be treated against his will only if he “demonstrates a danger to himself or others.” Given that virtually the only way to “demonstrate” such a danger is to enact it, this misbegotten law often has the effect of pushing psychotic young people into criminality.

“When my grandson was 11, we begged for help to keep him safe and out of trouble. Several psychiatrists later and many tears and meds for him, we were told: wait till he gets in trouble with the law. Then he will get help. His school told us the same thing. No one understood that what they were telling us was our fear!! We didn’t want this sweet soul of a kid getting into trouble with the police! We were not that kind of family, he was not that kind of kid! We were not going to let that happen! We would fight, pray, restrict him, take him to every doctor we could find. . .

“When mental illness takes hold of our kids we have no control. Mental illness wins over and over again. He is now 20 and hanging with some more worldly friends, friends whose families must have said and fought for the very same things. We must fight and tell the world how our kids didn’t have a chance. They did not pray for mental illness any more than one would pray for cancer. We need to fight for hospital beds in which to keep our kids safe. Our kids need to be able to have safe places to live, affordable meds, support and understanding of their illness. God hear my prayer!!!”

From this message, and others, it is clear that not even psychiatric doctors can be automatically trusted to have the competence and temperament necessary to help their patients.

“A bad day at the doctors. Our city had to basically shut down [its psychiatric care center] because of diverted funds, but after waiting a year, my loved one got an appointment, which was today. In the past year, we had seen a private psychiatrist who didn’t [ participate in my state’s Medicaid program], but would prescribe anti-anxiety meds to help [forestall involuntary confinement]. But she would no longer see him.

“The appointment started off badly as this new doctor called for security before my son even went into the office—possibly because of [troubling] paperwork he had filled out or because of his unusual look. In any case, the security thing set him off more than usual and the doctor made him leave and he is not allowed to return. I listened to the usual four-letter tirade all the way home, my son saying he would never go to another doctor again and don’t ever ask him to. He got out of the car before I came to a full stop at the house. I am so not looking forward to what will happen tonight. De-escalation armor on.”

And then there is the judicial system. As with psychiatrists and doctors, judges are commonly assumed (by outsiders and families of the afflicted alike) to be specifically educated in the neuroscience of chronic mental illness. They are assumed to recognize their moral duty to proceed with exceptional care and knowledge in adjudicating the fate of the most helpless people on earth. Doctors and jailers, of course, are bound by the same expectations.

A special test of that duty is their understanding—or lack of it—of the fact that the single most destructive action against a mentally ill inmate (in fact, against any inmate) solitary confinement, which quickly trigger and/or deepen psychosis.

Judging by the content of this mother’s message, her schizophrenic son has been failed by everyone in this chain. Both he and his mother have paid the price.

“My son’s court case is tomorrow. What’s tragic is the fact I begged for help since November 1. I faxed over a Do Not Release letter stating he was a serious harm to himself and me. Now, my son has spent three months in jail and has been allowed to deny all medications. My son suffers from anosognosia [a clinical term meaning “lack of insight into one’s mental illness”]. So, tomorrow, he learns the painful truth that his competency evaluation came back not competent to proceed.

“My son believes he aced [his mental competency test] and is coming home to me. But the doctor found him incompetent. No shocker there! If they had only listened to me back on November 1, he wouldn’t have had to spend three months and counting in jail! Plus, I wouldn’t have been severely beaten and cornered in my own bathroom [by him] for a second time. Now, my severely delusional child has been off all medication for a month. Talk about starting from ground zero!

“What he will experience tomorrow will be criminal. He will learn he’s incompetent, while wearing shackles and handcuffs. I fucking hate our system!!! He doesn’t understand his illness. His rights will be taken away. He will suffer from the phases of grief even though it is he who is lost to us. He will be left in a jail cell awaiting placement in the state hospital, which could take one to three months because the waiting list is so long.

“I begged with my son to call Disability Rights to represent him but he said he didn’t have a disability even though he’s received Disability for 5 years! What’s even more fucked up is that Disability Rights said they could only talk to my seriously delusional child. That is why he had to call! What a joke! I know so many parents who have lost their children with a serious mental illness in jail. So, please pray and send out positive messages into the universe that he makes it through, and finally receives the help he deserves!

This mother’s son was a small and thin 17-year-old, when local police arrested him for trespassing. The mother writes that, in a psychotic state, he had wandered into a neighbor’s house and fell asleep on a couch. The neighbors called police, and who, instead of taking him to a care facility, put him in jail. The mother has repeatedly called for compassion and treatment for him; so far, her calls have been ignored.

“Today is another day. It’s so hard to move forward with my life. We are stuck in this insane limbo. My son called today [from jail], and says mommy, ‘the inmates that hand out the trays they took most of the food off my tray. The guards were standing there. They said I have to pay a debt. They say I have to pay them if I want to eat. Put money in [X]’s commissary Account so I can eat.’ Over the past month, our son was in solitary confinement for almost two weeks. They stopped his antipsychotics cold for four days. He has psychosis, and is hearing voices. After the assault [by inmates] two weeks ago, he has a concussion.

“He’s been denied an MRI, or an emergency-room visit, despite my pleas. His vision is blurry, headaches, and nausea. He is emotional from the head injury. They will not wake him for his morning antidepressants. Now tonight he has informed us they are trying to extort money by starving him. So he was crying again tonight. We hope next month he sees the forensic psychiatrist.

“[The jailers] extort money for visits, commissary, basic necessities, phone calls, fees, per-day jail incarceration fees, fines, restitution, medicines, doctor fees, etc. Our son was charged as an adult at 17. The boy who dances like Michael Jackson, and plays 5 instruments. He hears voices. He has auditory hallucinations, and Asperger’s. Fifteen times, I tried to hospitalize him. Instead He went to jail where he spent weeks at a time in solitary confinement. He was beat up, his vision is still affected. He still had not had an mri.,. Tonight he sits in jail at just 18. He is not a hardened criminal. He’s a good, sweet kid, he wouldn’t hurt a fly. Every day I pray he will come out of this alive. My heart is shattered!

Here is another example of solitary confinement used as a blunt instrument—to effectively punish the victim of a jail beating.

“I just got off the phone with my son. He was beaten up two weeks ago [by inmates], and the jail’s answer was to put him in lockdown [solitary confinement] for 23 hours a day by himself. I had him agreeing to meds but they gave him the wrong meds and now he won’t trust them. He has been in the county jail for six months, and finally saw a judge for the first time last week. Now they need six weeks’ revaluation. Meanwhile, they keep him alone in lock up. He can call me on his hour out. He just called screaming and crying to get him out. I can only tell him he needs to hang in there and we are doing the best we can. But he’s slipping more. And nobody in the courts seems to care. My heart is breaking. His birthday is Wednesday. I am a single parent, and he’s my youngest.”

And here is another example of the foolish inadequacy of “danger to himself or others.” Given that virtually the only way to “demonstrate” such a danger is to enact it, the law generally does more harm than good.

“The doctor told me, “‘Wait, N—, he’s not bad enough yet, he hasn’t committed a crime!’ [And then he said], ‘Your son is an adult. He has the right to be crazy if he chooses.’

My son has slipped through the cracks in every instance. There’s no consideration for families living with an untreated psychotic person except when it’s too late. We live in fear of our own son.”

SPEAK OUT!

Scott Walker By Michael Vadon (Own work) [CC BY-SA 4.0 (http://creativecommons.org/licenses/by-sa/4.0)], via Wikimedia Commons

My upcoming book’s title, NO ONE CARES ABOUT CRAZY PEOPLE, is intended as ironic: it is taken from a notorious, subpoenaed email written in 2010 by an administrative aide to Scott Walker. The aide was trying to shield the then-Milwaukee County Executive from accountability for a mental-hospital scandal that was unfolding at the time.

In the few weeks that I have been publishing this blog, I’ve found myself thinking about an alternative title, one that lacks irony and only somewhat overstates the truth.

That title would be: NO ONE KNOWS ABOUT CRAZY PEOPLE.

For centuries, society has hired, or elected, custodians to see to it that the mentally tormented are kept out of sight and out of—well, out of mind. Those who take for granted their place in the “normal” world prefer to sidestep the colossal moral challenge—the primal fear—triggered by walking, talking evidence that people very much like them can go insane. (“There, but for the grace of jails. . .”) Thus, the mentally ill continue to struggle for their humanity under a cloak of social invisibility, and silence.

None of this is to suggest that people in the throes of psychosis should be left to roam the streets. Hospital treatment and supervision are imperative during such episodes. The problem is this: despite the growing consensus among research psychiatrists that a patient’s integration into a sympathetic community can dramatically reduce the symptoms of brain disorder, progress toward this goal remains slow: impeded by the cloak of invisibility and silence.

Few people have better understood the human spoilage guaranteed by this cloaking than the great pioneering reformer Dorothea Dix, whom I quote in the epigraph to NO ONE CARES ABOUT CRAZY PEOPLE. In remarks to the Massachusetts legislature prepared in December 1842, following her tour of mental asylums in the state, the small and sickly crusader declared:

“I have come to present to you the strong claims of suffering humanity. I come as the advocate of the helpless, forgotten, insane men and women held in cages, closets, cellars, stalls, pens; chained, naked, beaten with rods, and lashed into obedience. . .”

Time has brought improvement to the plight of insanity victims caught in psychosis—the untreated, the undiagnosed, the wrongfully incarcerated, those who refuse to confront their illness and aggressively repel efforts at help.

Time has not brought enough improvement. Not early enough improvement.

The cloaked suffering of the mad thrives, and it thrives. NO ONE CARES is laced with accounts of insane jail and prison inmates, many of them unindicted, who took their lives in their cells or in solitary confinement (I hope against hope that you might read this, Governor Chris Christie of New Jersey, and reverse your support for this gruesome form of soul-murder), and who thus died beyond the range of public attention, save for a few readers of transient news accounts.

Thus, “No One Cares” is fed by “No One Knows.” The two collide, and collude.

Thus far in this essay I have focused on the “invisibility” aspect of “No One Knows.” Of equal destructive importance, I believe, is the silence. The self-imposed silence that mutes the voices of those most entitled—and, I think, obliged—to break the silence.

I speak of the close friends and relatives, parents especially, of the afflicted. These people are qualified not by professional training or certification, but by a precarious vantage-point that no one else can share who are uniquely qualified by direct observation with psychosis.

And yet here is one of the most desolate truths about “No One Knows”: it is far too often a by-product of silence. Self-imposed silence. Silence maintained by those closest to the victims of mental illness who are in active psychotic states. This usually means their relatives. Typically, “relatives” means parents. And “parents” often includes the sub-category of single mothers, women who for one reason or another have been left to care for their volatile children—often male children, as a statistical fact. (Men typically develop schizophrenia between ages 15 and 24; women, between 25 and 34.)

Left to care, and left to scream in silence as police and community social-service agencies designed to help them often fail during episodes of crisis—or in pre-crisis. Police remain under-trained in this area, or not trained at all. In too many cases, the desk-man either shrugs off the frantic phone call or the squad arrives only to make matters worse. Paramedics and social workers feel hamstrung by coils of legal restrictions created to protect the civil rights of people in psychosis who “reason” that they don’t need help. (People in psychosis are, by definition, people deprived of reason.)

And so the family caretakers scream in silence—while their deracinated children scream aloud their suicide threats or violent threats against others, often including the caretakers, as the untreated psychosis deepens. and the cop on the phone explains (in essence) that the screamer cannot be detained unless he or she “constitutes a threat to others,” and that the uttered threat is not enough; the psychotic victim must actually carry out the threat, which, of course, in theory, law enforcement exists to prevent.

The caretakers scream in silence. And their urgent silent screams go unheard by the world around them. And the cloak remains in its suffocating place.

The reasons for self-imposed silence aren’t hard to track down. They’re rooted in human nature. The fear of embarrassment—stigma—is a fundamental one. To appeal publicly for help for a struggling insane relative is to acknowledge that one has an insane relative. Most people live their lives outside the community’s spotlight. To step into its glow for any reason can be terrifying. The imagined shame and ostracism such an admission might bring on is a powerfully, and sometimes fatally inhibiting burden.

Anxiety over the future of the victim is another. What if everybody knows she is schizophrenic? She will never get a job! She will never have friends! She will never marry!

And then there is the soul-crushing factor of futility. America, especially rural and suburban America, remains dotted—clotted—with service agencies, police departments, and courts that remain either stubbornly self-anesthetized to the gothic realities of psychosis, or else are paralyzed by the fear that any action they take might violate some law or statute or other restriction, real or imagined, that would make them civilly liable or criminally accountable for carrying out a good-faith intervention. Thus, far too many desperate mothers and fathers have called police, hospitals, lawyers—anybody—for help, against a background of menacing threats and the pounding upon a locked door, only to be told: “There is nothing we can do.”

This is surreal. This is grotesque. This is beyond the imagination of anyone in the “normal” world; only those who have endured it can appreciate the resulting dread that soaks the heart and blots out hope.

Schizophrenia has struck at both my children; once, fatally. I understand the heartbreak, the dread, the galactic frustration of my fellow survivors and sufferers who must watch their loved ones slip into a state that the world would prefer not to hear about, nor try to heal. I understand the powerful protective wish to remain silent.

And yet, in my core, I cannot accept the silence. I cannot accept it because silence is the lifeblood of “no one knows,” which in turn is the lifeblood of “no one cares.”

In my core, I want to confront all the silent sufferers—“confront” is the only word—and shout at them to shout their stories from the rooftops: to badger the newspapers and radio and television stations in their communities to pay attention to their stories, and amplify them, urgently and accurately, and damn the risks of stigma and anxiety and imagined futility. I want my fellow sufferers to raise a collective voice all across the nationwide archipelago of the mentally ill. I want an impassioned, fearless grass-roots movement to rise up and intersect with the hopeful, but top-down breakthrough of the recently enacted 21^st Century Cures Act.

I want the “invisible” mothers and fathers and caretakers of our most helpless citizens to take up the banner of Dorthea Dix, and affront the conscience of emergency responders, police, doctors, judges, and the largely oblivious and benumbed legislators across the country. I want to see a great and vital conversation burst into public awareness: a conversation that until now has been conducted under the cloak: in furtive telephone calls, emails, hushed conversations, and within the several “confidential” websites where members may speak candidly under strict rules of confidentiality.

All these conversation forms are cathartic. None is enough.

I grant that my career choices have annealed me to public exposure and its consequences. My training and experience, now spanning five decades, has been in journalism, which has in turn led me to nonfiction narratives. Over this time I have learned gradually to overcome my own severe native reticence, and to place truth-telling (as I understand it) above all other considerations. I have grown comfortable with violating my own privacy. NO ONE CARES ABOUT CRAZY PEOPLE, if it is nothing else, is a testament to this.

I respect—I ache for—my good, grieving, terrified sisters and brothers who cannot yet imagine shouting their stories from the rooftops, seizing the world by its lapels and screaming, “YOU’VE GOT TO PAY ATTENTION!” I wish I could deliver them from their agony. I cannot. The hard truth (as I understand it) is that they must do it themselves, until their individual voices meld into one continuing thunderous voice. We must throw off the cloak. No one will do it for us.