The Catch-22 that hovers over mental illness and competency

By Michael Judge

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Few familiar with the case were surprised last month when a federal judge in Tucson found Jared Loughner - the young, severely mentally ill man accused of killing six people and wounding 13 others, including Arizona Rep. Gabrielle Giffords - incompetent to stand trial.

To be deemed competent, Loughner, who suffers from schizophrenia and has refused treatment, must be able to understand the 49 federal charges against him and assist his lawyers in his legal defense. The judge, weighing recent psychiatric evaluations and the young man's delusional behavior in court, ruled he was not.

But thanks to second-generation antipsychotic medications like Clozaril, there's every chance that a court will eventually find Loughner competent. His next competency hearing is Sept. 2, and the court will likely order that he be medicated before that date. Whether he was sane at the time of the Jan. 8 shooting is another question, which will no doubt be vigorously argued if and when he stands trial.

The Catch-22 here is that if Loughner and other untreated, severely mentally ill people who commit violent, often senseless, crimes had been properly medicated beforehand, there's a good chance the crime would never have been committed. Untreated mental illness - not carrying a diagnosis of mental illness - is what raises the risk of violent or criminal behavior.

“We're willing to involuntarily medicate psychotic individuals so we can convict them and incarcerate them, but not medicate them to help them live safely in the community to begin with,” said D.J. Jaffe, founder of Mental Illness Policy Org., a non-profit dedicated to providing policy makers information on treatment.

“What we need is mandatory treatment before a person hurts someone, not after. This can be ordered by a court of law after a psychiatric evaluation as part of an outpatient commitment process.”

Such laws already exist in nearly all states, including Iowa, but are rarely used due to a failure to focus resources on the most seriously ill.

What most states now call “assisted outpatient treatment” laws have seen similar positive results, when used. A 2009 Duke University study found that patients with violent tendencies given assisted outpatient treatment were “four times less likely than members of the control group to perpetrate serious violence after undergoing treatment.”

Sadly, however, many people suffering from severe mental illnesses still don't get proper treatment until it's too late. Jesse Fierstine, a 34-year-old Iowan from Manchester, is one of them. Back in 2009, the voices in his head told him his father's pacemaker was killing him. So, Jesse cut it out with a knife. His father survived the attack, but later died of ongoing heart problems.

After several competency hearings and a long period on medication while incarcerated, Fierstine was finally found competent to stand trial. Hoping for leniency, he pleaded guilty to charges of willful injury, going armed with intent, and two counts of assault causing serious injury. His sentence on June 6: 20 years in prison.

Before the sentencing of her son, Donna Fierstine told the court: “Jesse loved his father. He was trying to help him - not hurt him. His father knew that, and blamed his son's illness - not his son - for his actions. ... Clearly, prevention of a severe mental-health crisis is the wisest course, rather than damage control after the fact.”

Proper treatment can't undo Jesse Fierstine's actions or bring back Webdale or victims of January's horrific shooting in Tucson. But it might, one can hope, make tragic events like these less frequent.

Michael Judge, a former deputy editorial features editor at the Wall Street Journal, is a freelance journalist who resides in Iowa City. Comments: Michael.Judge@wsj.com