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Insight
September 14, 1998
Reprinted with permission. Copyright 1994 Insight. All rights reserved.
The devil in deinstitutionalizing
By Sean Paige
Summary:
The 30-year movement to free the mentally ill from 'snake-pit' institutions may have proved a failure. But the best policy for helping psychiatric patients has yet to be found.
Text:
Russell Weston, Jr.'s, July 24 invasion of the U.S. Capitol building, which left two police officers dead and a tourist wounded, brought to a violent climax a private war the gunman was waging with a government he suspected was out to get him. But yet another war long had been raging within Weston himself, with reason gradually surrendering to schizophrenia.
Weston was investigated by the Secret Service in 1996 for threatening the president, and later that year spent time in a Montana psychiatric hospital after threatening another man. Why was he free to kill rather than in a psychiatric hospital getting the supervision and medicine he needed to keep his demons at bay? Those who ask that question regard Weston's victims as three more casualties of "deinstitutionalization" - another well-meaning "movement" rooted in the 1960s.
Complaints about the systematic emptying of state psychiatric facilities and attempted mainstreaming of the seriously mentally ill tend to resurface when people with a history of mental illness suddenly lurch from the realm of the slightly deranged to the ranks of the criminally insane. Although most of the mentally ill never have brushes with the law and more often are victims than victimizers, it's these high-profile cases that have led to a wary public's perception that the streets are filled with time bombs waiting to go off.
Beat cops and prison guards increasingly have become the custodians and caretakers of last resort for the mentally ill, observers say, as released patients become street people who in desperation turn to drugs, prostitution and crime - petty as well as capital. Moreover, the accelerated exodus from mental institutions in the 1970s by now is widely acknowledged to have resulted in the explosion of homelessness in the 1980s although it was long fashionable for advocates of the homeless, the late Mitch Snyder foremost among them, to blame the phenomenon on a housing shortage caused by heartless Reaganomics.
In any case, say civil libertarians, the inhumane era of warehousing the mentally ill in "snake-pit" state hospitals, out of sight and mind, simply had to end if we were to call ourselves civilized. Period. End of discussion. After all, Weston and others diagnosed as mentally ill have the same rights as other Americans.
And besides, deinstitutionalization would have, could have, should have worked much better and resulted in far fewer human casualties, its architects insist, had budget cutters not slashed spending on mental-health care and community-support systems as the mentally ill were being put out on the streets.
In the 1950s, media muckrakers and government commissions took up the horrifying conditions prevailing within some state psychiatric hospitals, giving impetus to John Kennedy's proposals for reform eventually incorporated into the Community Mental Health Centers Act of 1964, part of President Johnson's Great Society. The responsibility for managing mental-health problems that traditionally had fallen to counties and states was taken up by the federal government, a shifting of burdens and costs that cash-strapped locals welcomed. In 1966, state and local governments were paying 98 percent of the costs for the mentally ill; by 1994, the federal share of those costs had risen to 62 percent, with the state and local share down to 38 percent.
Experts say the mentally ill have been victims of both the political right and left due to a rare convergence of focus. Liberal civil libertarians saw so-called warehousing of the mentally ill as an inhumane denial of their rights, and fiscal conservatives saw calls for closing expensive public hospitals and shifting their care to a community setting as budgetarily sound. Although many proponents of deinstitutionalization now admit that they were over-idealistic at the outset, and grossly underestimated the challenge of helping the mentally ill manage themselves outside a controlled setting, the idealism of the sixties gradually has given way to more realistic assessments and approaches in the nineties.
While calls for reinstitutionalization are rare, many professionals in the field are seeking a better balance between the rights and needs of the mentally ill and the safety of the communities in which they live.
Among the most prominent critics of deinstitutionalization is E. Fuller Torrey, author of two books on the subject, who calls the effort "a failed social experiment" which has gone "disastrously."
Torrey says the scheme had little to do with alleged budget cuts. "First of all, budgets weren't cut," Torrey tells Insight. "They're much higher now than they were when we began deinstitutionalizing." The biggest problem, according to Torrey, was naive - the "increasingly fanciful idea on the part of some in the civil-rights movement that there really wasn't much wrong with these people," leading to the idea that mental hospitals could be emptied en masse.
And they have been. According to Torrey, psychiatric hospitals, which housed roughly 560,000 patients in 1955, today hold fewer than 70,000. And although the majority of patients probably are faring better on the outside, Torrey points to a 1995 study showing that 38 percent of patients released from state hospitals in New York "have no known address within six months of their release" as proof that some are faring worse.
Equally troubling to Torrey is the lack of sound science undergirding the effort from the beginning. Only one (probably flawed) study had been done on the subject when the movement shifted into high gear in the 1960s, he says, showing that "the original underpinning was political correctness, not scientific knowledge."
That's "garbage," according to Boston University's Marianne Farkus, who says Torrey accentuates the negative cases and wrongly believes "that people cannot be trusted to make their own choices." Indeed, "he strikes a chord people are willing to have struck, which is fear," she says. Farkus, a Canadian who studies how other nations deal with their mentally ill, believes the United States is less tolerant of them than most other countries because, "in America, the notion of asking for support is directly contradictory to the national ethos," which is independence and rugged individualism.
One reason deinstitutionalization faltered early on was that many psychologists, psychiatrists and social workers on the outside were ill-prepared and poorly trained for dealing with the seriously mentally ill who were being released, Farkus says. Until that time, very little attention had been paid to those locked away in hospitals. "If you were a star in psychiatry, the last place you'd want to go was a mental hospital that was dingy and dark and smelly," she says. And so community health centers, or CMHCs, tended to cater to the marginally ill, while mental-hospital exiles were slipped in the back door and languished at the end of their waiting list. In the 1980s, some 15 years into the process, a study by the National Institute for Mental Health discovered that few of the deinstitutionalized were receiving aftercare at the CMHCs.
Ken Dudek, executive director of New York City's Fountain House, which since 1948 has provided a wide range of support services to the mentally ill, has no illusions about both the downside of deinstitutionalizing and the complexity of solving our nation's mental-health conundrums. Dudek says that those resources that do trickle down to community-based support systems often are diverted to help the marginal cases treating problems such as anxiety disorder - at the expense of the seriously mentally ill. "As the community mental-heath establishment has grown, those competing people whose preferred method of treating has been some sort of talk therapy" have siphoned off funds that might have helped the more seriously afflicted, Dudek tells Insight.
He takes a harder line than many on the subject of the mentally ill who commit serious crimes. "Unfortunately, there comes a time with some people that they choose not to get any help, and then it becomes a criminal issue," he says. "I support the idea that if someone with mental illness does something criminal they should be treated by the criminal-justice system" because "it has been my experience that there have been very few people who have been that unconscious of what's going on."
Institutionalization of the seriously mentally ill often is best for the patient, some professionals point out, given the alternatives. "I consider the children who are institutionalized as a result of their disability to be the lucky ones," says Norman E. Friedman, who runs Hawthorne Cedar Knolls, a residential mental-health facility for youth in New York state. "The ones who don't get institutionalized end up in the streets, in the drug culture - they're the kids who die on the streets."
While they still are far from ideal, today's psychiatric hospitals are considerably improved compared with the dark days and still may be the only alternative for a minority of mentally ill who cannot safely make the transition into the wider world. "But unless there are proper alternatives for institutions on the outside, deinstitutionalization will be a nightmare for our society," says Friedman, "and we will pay far more later for what we're not putting in today."
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