AMA Journal of Ethics^®

Fred Friedman, JD, has spent most of his career working at the intersection of mental health and the law. He trained as a lawyer and practiced for many years. He has been an advocate for mental health legislation in the state of Illinois. He educates Chicago police officers in how to interact with patients who are having mental illness crises and medical students on how to better understand the needs of mentally ill patients. Mr. Friedman has struggled with mental illness himself. His narrative as told to Laura Blinkhorn, MD, touches on his experiences as a lawyer, a patient, an advocate, and an educator.

Being a Lawyer

I was always involved in social justice issues, but I was never involved in mental health issues. I never revealed myself as having a severe mental illness. What I would do is I would stop. I would reinvent myself. So when I got out of law school, I worked in a small law firm and I got sick; I attempted suicide. And instead of going back to the law firm, I started my own practice because I was just too ashamed to go back and deal with my former colleagues. After I had started my own practice I had built it into a nationwide practice. I had clients in 22 states and had 5 associates. I was very good and my clients were better off for having me. But I got sick. And again rather than getting better and going back to those clients I just stopped practicing law.

There were two things. One was the shame and the inability to confront, to talk to my clients, and the other was the feeling that I just couldn’t practice law and that I would hurt my clients. I certainly didn’t want to practice law and hurt my clients.

It’s like being a doctor. If you were a doctor and you committed malpractice, part of your worry would be that you’d be guilty of committing malpractice and that you’d have to pay a large fine, but I imagine another part would be that you had committed malpractice and instead of helping your patient you had hurt your patient. It must be a hard thing to bear.

The nature of my illness is that I become dysfunctional. I lie in bed. I’ve been saying this for a long time now. It is actually more complicated than that. What actually happens is that doing things becomes increasingly difficult, and one of the first things that goes in practicing law is writing briefs or answering the phone or that sort of thing. And then eventually, almost always, it turns into I don’t get out of bed. Now if I don’t get out of bed then I can’t really represent my client. I suppose what I should have done is told somebody that I was getting sick and have them pick up the slack, but I just never did. Because I was just ashamed. So it would generally develop into a disaster. A brief wouldn’t be filed when it should have been or there would be a court date I wouldn’t show up at. And then for a long time I would attempt suicide. Or something else similar to that.

So I get sick, I get better, I get sick again. Eventually the symptoms always leave and when they leave I am able to reinvent myself. That comes from lots of support. I’m very lucky. I had a lot of support and I am well educated. I was able to reinvent myself. Most people, many people can’t. Once they fall they can never reinvent themselves. For 25 years I had my wife to support me. And when I stopped having my wife to support me I went into the nursing home where I spent 3 years trying to reinvent myself.

Work provides a lot of services. It provides money. I would certainly be a lot better off if I had worked all my life, for the last 40 years. I would be better off, I would have a different, if not better, sense of community.

Being a Patient

I admitted myself voluntarily to the Institute for Mental Disease (IMD), which is a kind of nursing home that serves people with mental illness. In the nursing home, they had no expectation that I would get better. In fact they made it almost impossible for me to get better. One way was the sort of joke therapy. Art therapy class, for example, consisted of coloring books. I don’t know what that was supposed to do, but it didn’t do anything for me. Another was a current events session that consisted of reading the newspaper out loud. Again, that didn’t do anything for me. There was a session on teaching me how to live in the community, which consisted of taking me on a walk around the block.

I had a case worker and every once in a while I would go to see her and she would have me sign something. I later found out that what she had me sign were my goals. She didn’t ask me what my goals were. She didn’t even tell me what my goals were. And it turned out that the goal that she gave me was losing weight because I was obese. Out of all my set of problems—I’d lost my house, I’d lost my wife, I’d lost my job—being overweight was not the problem that I wanted to work on. And since they fed me, it seemed particularly atrocious. And they gave me a med—I didn’t know this at the time—Depakote, which frequently has the side effect of weight gain.

So they were perfectly happy for me to not get better. And they put roadblocks in the way to getting better, apart from the $30 a month spending money, which of course makes it impossible. How can you look for a job or even go out for a cup of coffee on $30 a month? A ridiculously small amount of money. So I spent $12 a month going to see a therapist at Jewish Family Services who was more supportive of my work. My case manager never talked about my getting a job or moving out of the nursing home. The clearest example of this was when I told them that I wanted to move out and they said, “You signed a contract that said you have to give us 30 days’ notice.”Now, as a lawyer, I can’t imagine how I could be crazy enough to need a nursing home but sane enough to sign a contract that would bind me. But putting that aside, when I said I wanted to leave, I talked to the director of services and he said, “You know, Fred, if you wanted more help, you should have asked. You should take more responsibility.”And I thought, “I checked into a nursing home. You’re telling me I should have done more?”It’s as if I went to the emergency room with a broken leg but didn’t walk up to the orthopedist.

They put all sorts of barriers in my way so I couldn’t leave. They gave me tests. It may just be classist. Among other things they tested my ability to tell time. So they would tell me it was three o’clock and have me write the hands on a clock. Or count change. And what I liked best was they asked me if I was going to prepare a spaghetti dinner what would I need? And I told them. And I failed this test because I didn’t propose a green salad. Now in the real world, I’ve made lots of spaghetti dinners. And sometimes I’ve had a green salad and sometimes I haven’t. And they got paid for keeping me there, not for getting me better. They had no incentive for me to get better.

I was scheduled to leave when my father got sick. I had arranged to move out of the nursing home and into a homeless shelter because it was a better place to live than the IMD. I had given them 30 days’ notice and I was waiting for the 30 days to disappear. And they had given me all these reasons not to go. And my uncle called. The stigma of mental illness was so strong, no one had told him I was in an institution. My parents, my wife, we just never told anyone that I was sick. When he told me, “Your father is very sick; you have to come see him,”and I said, “Well I’m not sure that I can,”he was very confused, and he said “What do you mean?”He said “I’ll pay for it if that’s the issue.”And I said that it wasn’t really the issue though it was part of the issue. Mostly it was that I needed permission to leave. And they, in fact, gave me permission to leave and my uncle paid for my trip to Florida and I was lucky to get there when I did because my father died the next day. And at the same time my sister was in the hospital. So I decided to stay in Florida until she got out of the hospital.

I told the nursing home that I had lost my space in the homeless shelter I was going to go into because they don’t hold those spaces very long. So I stayed for a few weeks. And buried my father, took care of my sister, lived on my own. After 2 weeks, the meds ran out. One would think that was a sign that I could live on my own. Instead, when I got back to the nursing home, I went back to my room and they had plugged my lock—putting something in the lock so the key doesn’t work. And the whole purpose of eviction law is to prevent landlords from doing that, so that you have to go to courts, you don’t just evict somebody.

And as I was standing there thinking about it, someone came up to me and said, “The ambulance is coming to take you away.”And I said, “What do you mean?”And he said, “We called the ambulance.”And I said, “Why?”And he said, “Because you were without meds for a couple of weeks.”And I tried to figure out what to do. I had a few hundred dollars in my pocket that I’d gotten from my father. But that wouldn’t last very long. The ambulance came, they tied me up, put me on the gurney, and restrained me. And I remember the guy asked me if I knew what the date was. Now I’m not very good at remembering what the date is because normally I look at something that tells me what the date is. Since I didn’t know the date, he said I was disoriented.

I went to the hospital and they started interviewing me. And I said, in my legal opinion, not taking my meds is not grounds for putting me in the hospital. And they said, “Well that may or may not be true, but if you’re wrong you’ll end up at Elgin and you really won’t like Elgin.”(Elgin is the big public psychiatric hospital).

Since I had only a few hundred dollars in my pocket— probably less than $200—and wasn’t sure I’d win that fight, I signed a voluntary commitment and stayed there. I just turned my head to the wall and gave up. My father was dead, one of the two people who talked to me who wasn’t paid to talk to me. I had no place to live. And was behind a locked door, which I really really really hate. So I suppose from their perspective I was displaying symptoms. I stayed there for 4 weeks. Why did I stay there for 4 weeks? Because Medicaid pays for 4 weeks of hospital care. So as soon as Medicaid stopped paying for it, I got well. And they told me to leave. I don’t know what they could have done for me in 4 weeks except give me meds. And that was very scary. There were people who were actively psychotic. It was just very scary. I don’t like forced treatment. I don’t trust their motivations for forced treatment. Indeed, when I asked them at the nursing home why they did it, they said that they had to protect themselves, “we have to cover our ass,”which doesn’t really strike me as a good reason.

Being an Advocate

After being in the nursing home, I went to a homeless shelter. While I was in the homeless shelter I went to visit the director of the program who had actually by coincidence been a friend of mine many years ago when I was a law student. And we were chatting and I told her I was thinking of getting involved. And she reached into the trash basket and pulled out a flyer about a meeting about Continuum of Care meeting in Chicago and a new model that they were proposing called “housing first.”And I went to it.

At that time, and in some cases still, the prevailing model for offering housing to people who are homeless was “housing-ready.”The housing-ready model says, “We will give you a home when you’re ready for it. And if you’re not ready for it, then we won’t give you a home.”So the emphasis was on fixing the homeless person rather than providing a home. “Housing first”says first you give someone a home and then you try to fix whatever is wrong with them. Housing-ready is sort of like saying, “We’ll give you insulin if you get your blood sugar under control.”It strikes me as silly. And now almost everyone agrees that housing first is the correct model.

When I was in the nursing home I was never going to get a house because I was never going to be ready. When I was in the homeless shelter, I was never going to get a place because I would never be ready. So housing first was a very exciting concept. And then I became very involved both because I had nothing better to do and because I started attending a lot of the meetings and eventually wanted to join the board of Continuum of Care. And they said, “You can’t.”And I said, “What do you mean I can’t?”And they said, “Well, you’re homeless. We can’t have homeless people on this board, that’s a conflict of interest.”That doesn’t make any sense. And I said, “Show me“—at that point I was better—and I said, “Show me where it says that.”And of course it didn’t say that. It said homeless people should be involved in the process. So I became the first person on the board who acknowledged the lived experience of being homeless, and, by the time I left, 25 percent of the board were homeless or had the lived experience of being homeless. And for years the head of the board was a homeless person, which I believed was a remarkable experience, and still do. But then people started saying, well you’re not really homeless.

The reason I wear the “I’m one of those people”t-shirt is that I was in one of those meetings arguing about housing first and one of the providers said, “You guys don’t understand this. Homeless people are like wild animals. They need to be housebroken before you can let them inside.”So I raised my hand and said, “You’re talking about me.”And they said, “Of course, you’re different.”So I thought it would just be easier to get a t-shirt.

I formed Next Steps with two other people to empower homeless people in Continuum of Care. One of them died and the other decided that he needed to support his kids, so I found myself alone. I decided to conduct a fairly large survey. I personally interviewed 30 people and talked about what Next Steps should do or become and the conclusions of that discussion was that, since I identified more as someone who has a severe mental illness than someone who is homeless, I should at least work on mental health issues. So the mission of NextSteps expanded into empowering people with mental illness to become involved in the system. A couple of years ago we got a grant that asked us to become statewide. We became statewide and focus on mental health issues.

Being an Educator

I teach and so I guess I believe that with appropriate supports people with severe mental illness can do work. (Even though there are many times when I doubt it.)

There are three takeaway messages from any talk I give:

1. Anyone can get seriously mentally ill.
2. Getting seriously mentally ill can have disastrous consequences.
3. No matter how bad the symptoms are, people can get better. They can recover. It’s our obligation to create a system that helps people to recover. So now I’m struggling to find out what those appropriate supports would be.

In addition to that, I teach an 8-week recovery class in which people who have lost everything—or perhaps never had anything—how to recover. How they can get a job, find a place to live, form an intimate relationship. Part of it, especially in the beginning, is heartbreaking. Many of them have been taught that it is a bad idea to want anything. So if you want a job, you just don’t understand how serious your symptoms are. If you want an intimate relationship, you just don’t understand how serious your symptoms are. If you want a better place to live, you should be grateful for whatever hovel you’re living in. Now often, this advice is not given by bad people. Often these are people who believe that if you try and fail then you’ll feel bad. And of course that’s true. Try and fail, then you will feel bad. But if you don’t try, you’re gonna fail. The beginning step is to help people visualize what they want. Then help them make that more concrete. “I want a better place to live“—What does that mean? “I want a job.” What does that mean? And then help them set up paths to achieving it.