Some other countries have far better outcomes for psychiatric care. I wonder what they're doing right?
We have strangled budgets in the Unite States by looking the other way as the entities with the most resources -- corporations and money managers -- cheat our system, don't pay fair taxes [sometimes don't pay any taxes], help their employees to game the system, and then complain about the high cost of government.
We have abdicated our position as a "civilization." We no longer "take care of our own." We don't even admit to any connection to each other any more.
"In God We Trust" replaced "E Pluribus Unum." But God doesn't seem to be paying attention, now that we don't see our country fellows as kin.
14
Inequality is growing. The weapon industry continues to increase at an accelerated pace, to feed global wars created by corrupt governments and greedy politicians. Add to that the ravages caused by climate change. I am not an expert on anything, but it seems to me all of that is enough to increase stress in people's lives. Our nation's money ought to be used to improve the areas of health, education, nutrition, and the care of our land.
8
I'm not a psychiatrist but I can say that mental health here is totally neglected. I don't know about asylums but for God's sake at least some responsible reliable counseling with people who are professionals. And stop acting like having problems = death sentence.
12
"During this time, the number of public psychiatric beds available has plunged, to 11 per 100,000 people from 360 per 100,000 in the 1950s, according to Dr. E. Fuller Torrey, founder of the Treatment Advocacy Center,"
Right. But where should those beds be? In hospitals? Bad enough that people released from hospitals skimp on their meds (because they can't afford them) or don't take them (because they're in denial about their illnesses); but psychiatric patients off their meds are different from cardiac patients who don't take their heart pills.
Even close-knit families can't protect their schizophrenic children and siblings. Eventually many simply give up. Often their mentally ill loved ones become homeless and anonymous; sometimes they achieve notoriety when they kill someone -- a family member or a stranger on a subway platform.
Willowbrook was a nightmare. But there's room for a more enlightened version of Willowbrook -- much better than life, and death, on the streets.
20
Having worked as a Social Worker at the County level and then as an independent Psychologist, I can attest to everything that is said here. The argument that services in the community can be made available to keep these people in their respective homes rings hollow in my ears. Much as we would like to think this would be possible, there are no services that could provide enough care for this population. And one certainly cannot count on funding for such either. The Community Mental Health Centers are laughable. Staff turnover is pathetic and I am talking about the professional staff. One of my clients went for her appointment with her Psychiatrist only to find him gone. They sat her in a chair in front of a TV screen and she "met with" a Psychiatrist in Ohio...wait...WHAT???? The Center had to contract with a Psychiatrist 4 states away. I suppose it is better than nothing but the rural areas of this country are severely hurting for professional staff who are committed to staying for a while - at least longer than a year....:(!
18
Services for people with serious mental illness would be effective if they were sufficiently funded on a consistent basis. In order for that to happen, this issue has to become a priority for policymakers. Sadly, tragic incidents like Parkland committed by people with untreated mental health conditions seem to be the only thing that gets their attention. People with mental illness are rarely violent, so maybe this just isn't happening enough to truly make the point that change is needed.
7
Well, my mentally ill uncle Everett ended up dying homeless,( He heard voices in his head) found dead on a park bench- he had been dishonorably discharged from the Navy after serving two years ( Korean War). Back in 1984 when he passed away, it was in vogue to mainstream guys like him, never mind that he didn't get his meds and no half way house would accept him. My family considered him a disgrace and disowned him years ago. A kinder fate would have been a mental hospital ward.
34
My leftie friends always blame this problem on Ronald Reagan...even the NYT is smarter than that.
8
I worked in one of those "dreadful" institutions many years ago, and never once saw any bad treatment...except that some were kept in lock-down because of violent behavior. Then along came the "miracle" drugs, which were supposed to be the cure-all for every mental disease. The State hospitals quickly closed, and the patients were released with a prescription for pills (they usually forgot to take). They might have gone into half-way houses, but many simply went homeless. Others were picked up for criminal activity and sent to jail. Some of those spent a lifetime in and out of jail (where they were often abused by other inmates). Still, some preferred jail to surviving on the streets. (I actually knew one who committed crimes over and over again just to get back into jail!) Few families or communities have the means to care for such needy people. Therefore, institutions or hospitals are the only logical solution.
34
All well and good, but everything requires funding. Trump has no clue about costs. States are going to have to pay for their own infrastructure repairs and now Trump proposes more. At least when we had a Democratic president with a Republican Congress, they at least considered spending, but not anymore.
5
My daughter has a severe mental illness and once spent a week in an ER, at times strapped down, waiting for a bed in a psychiatric hospital to become available. My experience with the many ER staff I've encountered has been wonderful, but they are not there to treat mental illness.
We need more psychiatric hospitals.
And, sadly, some people are so severely ill that they need longer term care, this is one of, perhaps the main reason for our homeless crisis. Just because the asylums of the past were terrible doesn't mean we can't provide quality and caring long term care facilities.
We put a man on the moon, we can solve our mental health crisis, we just need the will to do it.
38
About 25% of psychiatric hospital beds are occupied by people with schizophrenia.
Traditional psychiatric treatment usually disparages experiences of hearing voices or having hallucinations as being totally negative and meaningless - something to banish with drugs. And relapses of psychosis are often common.
Following are resources regarding some alternative treatment approaches, which often use few drugs, and which may be especially successful with young people experiencing early episodes of acute schizophrenia.
(1) YouTube - "The Voices In My Head/ Eleanor Longden" - TED talks - Dramatic and insightful - (Best viewed using Mozilla Foxfire or Internet Explorer)
"I had always suspected that my voices were meaningful responses to traumatic life events, especially childhood events."
(2) Website - Intervoice - "A Practicl Guide To Coping With Voices" -
intervoiceonline.org
(3) Podcast - "Open Dialogue Alternative : Mary Olson" - madnessradio.net
- A Finnish treatment program
(4) Article - "A Conversation With Dr. John Weir Perry" - global-vision.org - Jungian residential treatment for young schizophrenia patients in San Francisco in the 1970's.
Staff members encouraged patients to freely express their inner voices and visions. Patients frequently reported metaphorical images of ego death and transformation similar to characters and themes from archetypal stories of the hero's journey into dark mystery.
Includes dramatic illustrations
5
Was it really necessary to use the antiquated term "asylum"? I guess I should be grateful that the even more pejorative term "insane asylum" wasn't used.
6
Our society is failing because we are not a society of humaneness, nor do we practice true christian values. As long as we continue to spend billions on unnecessary armaments to further enrich the 1% all the while echoing their sentiment that the downtrodden and most unfortunate in society are simply losers unwilling to get a job, nothing will change.
17
You are right about our priorities, but that still doesn't address the fact that many people with mental illness will never take their meds on their own; that their concerned, loving families cannot force them to take their meds; and that when they end up on the streets, they become a danger to themselves and, far too often, to others.
I'm afraid that people's right not to take their meds should end when they begin to threaten people's lives.
19
So the plethora of guns in the wild make us want to help the mentally insane because we want these people to get better: Rather it is to all the NRA to continue to add to the 1 million gun death tally that is growing minute by minute.
3
In discussions of the mentally ill, there is rarely much differentiation as to the different types of mental illness. Would it make sense to group all those with a physical illness in the same category with the same solutions? I think not.
Many mentally ill people are able to function in jobs and society with appropriate medication and/or psychotherapy or counseling, and no-one outside their immediate family and their medical providers know that they are ill.
On the other side of the spectrum are those who clearly cannot function in society and end up on the streets or in prison or as a constant danger to others.
Intelligent discussion really needs to differentiate between different types of mental illness and their causes (biological/genetic or trauma related) and the severity afflicting each individual, in order to assess appropriate methods of treatment and hospitalization.
17
First of all, I hate it when journalists get arch about one of Trump's ideas: "Strangely, perhaps, he has echoed an argument..." If we looked at everyone's ideas neutrally, including ideas from people we don't like (yes, even Trump!) then maybe this country could make some progress.
We have mental illness in my family (genetic). My family has resources, and I've watched them painstakenly research and find expensive residential programs all over the country that have gotten their adolescents through crisis stages and into sometimes shaky adulthood: but these are only for the affluent. Knowing what's available to the rich makes seeing middle class families struggle with mentally ill family members even more heartbreaking.
Affordable housing is obviously very important. When this is combined with tiered services ready to respond appropriately to minor and major crises, including long-term residential care if it's needed, then many people can lead lives more free of suffering, and even dare to pursue some happiness.
In the meantime, my activist family member has helped to bring a local chapter of a Clubhouse into reality. The Key Clubhouse of South Florida is for mentally ill folk who are stable. It helps them reintegrate into society and helps them get back to work: www.keyclubhouse.org
16
The current community care psychiatry model has failed and it’s time to consider safe places for those who need regular and ongoing treatment to receive it. This article ends with a cherry-picked figure about cost. It does not include how much it costs to move people through the legal system or provide for them in shelters.
At the moment psychiatrists and mental health teams are overwhelmed and have to scramble between home visits and hospital clinical appointments. Even when housing is provided, patients often live in squalor and are danger to themselves (e.g, leaving the stove on). Not to mention that they are left in the position of managing their own medication compliance.
They spend long periods of time alone with no structured social or occupational activities. Essentially they are left to fend for themselves. When they can’t cope they are punished by homelessness or imprisonment.
The current lack of beds means that they are often released prematurely, only to require stabilisation again in a few weeks or months- it’s a revolving door with no end or improvement in sight for them.
That reprehensible and horrific abuses were committed in the past in institutions cannot be disputed. We must re-examine our current solution which does not meet the needs of the chronic and severely mentally ill. If I developed a debilitating disorder that required ongoing care, I would hope there would be somewhere other than prison to get three meals and 24/7 access to medical care.
32
As a person who has lots of experience with a close family member who is bipolar, I agree that the current system is a failure, and if a family cannot spend over 100k out of pocket for 24x7 at home care per year, the patient will become homeless.
Today's psychiatric wards in hospitals in NYC are fine, but they discharge people without bringing them back to mental health because they have just a few beds.
I spent quite a bit of time searching for a nice facility in the NY metro area that would be more of a country club type of setting. I bumped into a couple but their costs were well over 20k per month. We decided the home care was better and cheaper, though it doesn't provide the activities that might benefit the patient.
I'm not sure that community care is an appropriate substitute as these patients can cause harm to themselves, or others, and need day round supervision. With this bipolar family member who is in her 60s, the latest episode has been going on for 2 1/2 years, has included 3 hospitalizations that lasted from 1-3 months, many dozens of ECT and more advanced treatments, and we still do not have someone who can function independently.
18
We have money to spend on incarcerating people who are homeless, who commit quality of life crimes because of their homelessness, who have abused drugs sometimes in an attempt to deal with mental illness but we don't have money to provide seriously mentally ill people with the care they need to be safe and to be as productive as they can be and happy. We're more than willing to let mentally ill people be isolated, at risk of becoming crime victims, committing a crime, or being killed or killing themselves but we don't want to provide them with the help they need.
We don't want to help able bodied people, handicapped people, developmentally disabled people, unemployed people, the elderly, or anyone who hasn't proven beyond the shadow of a doubt that they truly need help. As a result we wind up helping almost no one and hurting nearly every person who needs assistance. The only ones we truly help are the economic 1% and they don't need anything from us or the government. Yet where help would make a real difference we refuse to make it available.
America is not a charitable, compassionate, kind, or Christian country. We are an uncaring, punishing, and cruel country that abandons those who need the most help or even a small amount to keep going. We value our rights to own guns more than we value our citizens.
38
America is not a good Buddhist either. Certainly not a good Muslim. But we are pretty good at building stuff. Perhaps some 3D printed moral compasses with augmented reality goggles would help? And instead of first-person-shooter games, we could play compassionate first responder mode?
1
As a school administrator, I have been often struck by the burden community mental health places upon families. There is an assumption that family members have the time and skills necessary to deal with crisis. Too often abuse or neglect in the home is the tragic result. Providing quality (and that means well-funded) extended stay options would make families healthier and better able to assist their loved ones, and school learning environments more productive.
24
Patients can be admitted to psychiatric hospitals and patients can be discharged from psychiatric hospitals. But that in no way means that such patients have recovered, that they have received appropriate medical and therapeutic treatment or adequate discharge plans. Without the support of family or friends, they may be left isolated and alone.
16
When I received my masters degree in 1968 at Kent State University I thought I was embarking on a career helping people who suffered from mental illness.
By 1970 I realized that the entire country was no longer interested in helping their mentally ill neighbors through their taxes and my career was cut short.
I changed to rehabilitation counseling where I could specialize in career counseling with the mentally ill. For over thirty years I witnessed the mentally ill relegated to the streets as homeless and in the county jail.
America didn't turn out to be the country I was brought up to believe in!
25
In the 1970's the ACLU went to court on behalf of those institutionalized due to mental illness and the court ruled that the mentally ill could no longer be institutionalized. Thus, unforeseen consequences emerged.
7
America never was that country.
3
It was, in fits and starts, trying to become that country, but the 1% and their Congressional toadies put an end to it.
1
Yeah baby... an Arkham in every town, village and city.
Gotham will be great again.
A question about the Parkland shooting. There is virtually universal agreement that Nikolas Cruz is severely mentally ill. In fact, our president and his fellow 2nd Amendment above all supporters say this is the reason he did the shooting. However, the state of Florida doesn't even want to take the death penalty off the table much less let him plead not guilty by reason of insanity. How is it that everyone says he's crazy including the Governor and legislature of Florida but he isn't when he gets in the courtroom.
As to where to care for the mentally ill, how is we either fund outpatient or inpatient care. We don't choose between paying for dialysis or kidney transplant but make both available despite the cost.
8
Physician here. I did my psychiatry rotation in med school at a university-affiliated psychiatric hospital. I was assigned to the schizophrenia ward. Many patients stabilized on meds and were discharged within weeks, but the exception was a core of patients who had been transferred from the state mental facility.
One of these patients had raped dozens of young children and tried to corner me in a hallway. Another, who was 6'7", was incredibly violent with staff. He ambushed me and a medical assistant in the hallway. We were pulled to safety, but the MA (small young woman) was punched in the face so viciously that she catapaulted in the air-- almost cartoon-like. Beyond horrifying. Yet another patient masturbated at every waking minute and sexually assaulted ALL of the female staff and a disabled male staffer. The only way to keep him from assaulting us was to distract him with pornographic magazines. And these patients were HIGHLY medicated. The hospital was not supposed to keep patients for over 6 weeks, but clearly could not discharge these patients to the community.
I truly hate to admit this as a physician whose job it is to heal, but the idea that any of those people could be released to re-inflict their violence and sexual predation on the community is terrifying. Frankly, long-term care may be the only safe option for a small but real group of mentally ill patients.
56
Yes, I was a psychologist at a large state mental health facility which treated some sex offenders such as you describe. The state shut down the facility, choosing to place everyone into the community, with no other options available. Some did well but of course others repeated their offending patterns - entirely predictable, of course. Yes, there is a small core of individuals who will always need oversight and more secure placements, but we don't seem to be willing to provide this now.
28
Thank you for this. I see people in my neighborhood who are so clearly crazed -- and I do not use that word lightly -- that I can't believe they are on the streets. Their frenetic, often obscenely energetic and frenzied, behavior raises in me an entirely atavistic fear-reaction.
Which isn't to say that my family is immune or that I am unsympathetic. My maternal grandmother underwent shock therapy at Payne Whitney in the 1960s. Not pretty. Other family members had depressive episodes. Their behavior was nothing like what I've seen in on the streets of New York City. It cannot continue this way.
11
My first thought: Yes! Let's address the need for long term mental health care. My second thought: Trump just thinks asylums will work as "cleanup site" to get the mentally ill and/or homeless off the streets to benefit property values then slide into institutionalizing anyone who disagrees with him.
10
He is 100 percent correct.
Just because some asylums in the past were sorry places does not mean that the idea of ASYLUM is not The answer.
Feel sorry for these people sitting on chairs? Instead feel sorry for the jails which act like mental asylums but are ill equipped to do so. Take a walk around Berkeley, where the mentally ill have congregated in vast numbers, shouting at the sky and imaginary demons all night long without food or shelter, let alone drugs which may help their plight. Poor souls. 1 in 100 are schizophrenic! Got that 1 in 100. 300 million people, that means 3 million schizophrenics. And that is just one of the devastating mental illnesses.
24
Yes just try to get a long term placement for a severely mentally ill person in Alameda County. I have to no avail. In spite of their afflictions they need protection and so do we. This country is so inhumane.
9
Those people have chairs to sit in. They are not crowded into a cell with 15 violent criminal where they may not be allowed room to sit on the floor nor are they sitting on frozen ground. They will have food put in front of them three times a day. They are not rained upon.
3
Sorry to be the bearer of bad (or potentially good) news, but mental institutions still exist on a massive scale. They’re now called, “Skilled Nursing Facilities.”
6
Of the 33,000 Americans who die from gunshot each year about 2/3rds are suicides. And 80 percent are white men who tend to use a handgun. Most mentally ill people shoot no one. Instead of mental illness simple inhumane evil cruelty or criminality or rage is the motivation for most shootings.
6
There is no "one size fits all" answer to the long-term care of persons with serious problems in living!
Each of the major categories of problems in living require its own form of intervention and living assistance.
Unfortunately, significant modifications of the social situations in which the most seriously disturbed are located would require new, supportive situations.
The current medical model treatment provides no substantive answers.
New kinds of social psychological engineers are needed to design, test and put in place such large scale therapeutic communities.
5
You can build the nicest "treatment center" in the world and you can make it so "transparent" that it's almost "see through."
The problem is the minute you shut the door no one looks nor cares about what is happening at your new center and the next years budget comes around and some politician thinks; "I can cut taxes so billionaires and mega corporations get richer and we'll make up for the deficit by reducing fraud and abuse"
That's the moment the patients are condemned to a life in a warehouse yet again.
The problem if you don't build a "treatment center" is the patients with the worst problems just get tossed out into the street or sent to prisons...
Somewhere, Somehow, Someway we as a nation have to find a solution to the problem of mental health in this country.
Gun Bans won't stop those with mental health issues they're just another politicians smoke and mirrors trick that allows them to evade having to deal with the real issue -
This country has a mental health crisis on its hands and the politicians Democrat and Republican alike have done next to nothing to fix it in the last 40+ years which coincidentally is around the same time as when the last of the asylums closed
Currently and sadly very likely for the foreseeable future, the quality of mental health care in this country is and will continue to be a national disgrace.
8
The question is not where treatment is administered. It is what treatment consists of. And for the severely mentally ill, treatment generally consists of medications that are mind-numbing. Those whose conditions improve with medications like antidepressants are an easy cure. But there is no answer for those whose conditions defy treatment, and the ideas out there are neither humane nor effective.
4
Certainly there are mentally ill individuals that will require lifetime supervision and in some cases lifetime confinement to provide supervision.
After 35 years at the hospital setting and community setting; deinstitutionalization served several purposes, one to create client rights specifically to the least restrictive setting, secondly it was seen as a money saving move for states, with promises of closed hospital monies following the clients into the community for services.
The biggest failure for clients was moving from the hospital setting where all daily needs were met and financially covered to community based services spread out in a town or county; and now the client has to manage money for rent food, and basic needs. Clients once in the community now lived in poverty often in less than ideal neighborhoods. Yes, there are case managers to assist, but most community based programs, private nonprofit, have been flat funded for years. Integration into the community is limited.
Individuals with severe and persistent mental health disorders have a life long illness with poor prognosis and deteriorating physical and mental health requiring higher levels of care eventually.
Those individuals presenting as a serious risk of danger to themselves or others will require hospitals or other secure settings. Most state hospitals were built over 60 years ago and are inadequate in design for safety and providing services
10
"State governments, with some exceptions, did not make good on promises to provide adequate community care, like well staffed local clinics, supports for housing, employment and daily living.
Under budgetary strain, they offloaded much of the expense of mental health care to federal programs like Medicaid."
Many advocates including mentally ill themselves pushed to downsize or close institutions and provide care in the community. As stated in the article States were more than willing to oblige. One reason is that Medicaid fund are not available to people in state institutions with over 16 (I think) beds. One might have thought that each person discharged from the state mental hospital had a certain amount of money assigned to them --not so, The money saved by closing a hospital went back into the general fund and STATE money allocated for community treatment is decreasing year by year and more restriction are placed on Medicaid. If Paul Ryan has his way these funds will decrease further.
6
Several years ago I left a job at a public library for many reasons, not the least of which was having to regularly deal with mentally ill homeless or group-housed patrons who threatened violence on a regular basis. One of these patrons, whom I'd dealt with at a variety of branches across a large library system, threatened to kill me back in 1999, and then tried unsuccessfully to follow me home. Amazingly, I was still dealing with him 15 years later when I left my last public library job. By then, he'd been shuffled from group home to group home, and was engaged in suing his residence to retain squatters rights. By the time I left urban public library service in NYC and San Francisco after 17 years, I lost count of the number of times someone threatened to kill me. Aside from regularverbal abuse, I dealt with countless fistfights, 3 knife wieldings, drug overdoses, one overdose death, and one stabbing. My experienced co-workers who began work in the 1960's and 1970's, to a one, said that these problems began in the 80's when mental hospitals were closed. We shouldn't go back to the horrific practices we saw in mental hospitals in times past, but we must face the fact that closing the mental hospitals led to terrible unintended consequences in many areas of the public sphere. Community care and group homes are not the entire answer. I hope the idea of providing humane, effective care for mentally ill in hospitals, coupled with effective group home care, isn't a pipe dream.
53
In Germany, housing is guaranteed as a right. The government subsidizes the cost of living by offering a rent stipend between what a person could fairly pay and what the market determines. The landlords actually love it because they get guaranteed income. The problem in the U.S., especially on the West Coast, is that the housing supply is suppressed by bad public policy from Democrats and a lack of financial support from Republicans, who view housing as a privilege for boot-strappers.
Building expensive institutions to lock up people with mental disorders is neither fiscally responsible nor humane in all but the most severe and acute cases and it would cost a lot more than simply giving more housing vouchers to mentally ill people that gets them off the streets while they receive care in their community. At the same time, politicians needs to develop a spine and push back on the NIMBYs by allowing for more housing units to be built for everyone.
7
The issue here is not housing and whether landlords get paid, but whether those in need of care are receiving it.
3
No, you're wrong. Housing is a key social determinant of health. It's hard to impossible to maintain mental health stability when you're homeless. The Medicaid expansion provided access to treatment, but it won't work if the patient is still living on the streets.
8
Ask a landlord what dealing with Section 8 renters is like.
Then ask them about housing mentally ill lessees...
For a good hint, see the comment just above yours from NRichards about facing mentally ill individuals at work.
7
I'm not at all surprised that the thing in the White House is cheerleading this effort at a return to the bad old days of "mental asylums"; the term itself is a sick joke! "Asylums"? For WHOM? Certainly not the potentially innumerable "patients" who'd inevitably be caught up in this historically BAD idea. No matter how much proponents of bringing back warehouses for society's unwanted embarrassments; mentally ill people for whom very little money is ever allotted for them in any budgets, state, local or federal, which eventually means that, as populations inexorably rise, the ratio of psychiatrists to patients soon becomes an exercise in futility. How in the world can ANY patient in one of these dungeons ever receive the care they need and deserve and that would enable them to have hope of getting out of there & back to the freedom they, as all citizens, deserve? When you have one dr. responsible for up to 100 patients, many of whom will rarely, if ever, actually meet, face-to-face with said dr., but instead will be hustled around, like so much cattle by nurses, the rising ubiquity of the use of "physician's assistants', who, in many medical settings, not merely mental-disorder-related cases, are, due to the lack of available MDs, are becoming the providers of care for most Americans when they have a need for some sort of non-emergency medical care. No, this is a horrible idea. Any doctor with any credibility would never consider this, at least, and at most, oppose it.
3
I'm sorry but the way that severely mentally ill live now is no better on the street than in an asylum. They're subject to sexual and physical abuse there too. They live in squalid shantytowns. There have been large outbreaks of Hepatitis A in San Diego and Los Angeles among the homeless so they're getting and spreading disease among each other. And there's no physician whatsoever to help out there on the street. I think most can agree that the asylum as it was is not something that's an acceptable solution these days. But a hospital that specifically caters to mental illness, that's well-funded, run by capable well-paid competent staff and lots of oversight is a darn site better than life on the street. Problem is nobody wants to spend the money which has essentially led to the situation we've got today.
10
What to do with them? CARE for them. Take them in from the streets and help them. I clearly remember the start of the homeless crisis in the city in the '60s when the asylums were considered 'bad'. Instead of improving them the idea was to integrate people with mental issues into the population. See how well that worked out.
13
Did you read some of the other comments? A percentage of the people living on the streets is too dangerous to simply integrate into the general population and should be confined.
1
Dr. Torrey said, “There’s simply nowhere to put people with severe mental illness to stabilize them ... No one seemed to care ... when so many [became] homeless. ... Now that they’re going to prison[. If] there were beds available, you wonder how many of these tragedies could be avoided.” Probably, 80% of such tragedies.
I immigrated to US in 1971. I worked in different mental hospitals since then until 2010 in different State mental hospitals in MA, MO & IL. The vast majority of patients were treated humanely with dedicated low-paid staff. And unbelievably cost-effectively. Virtually no abuse was there, except rarely in a maximum security hospital for the "criminally insane" patients. Meanwhile mental hospital beds shrank, gradually first & rapidly later to the point of non-existent, except for a few criminally insane.
The vast majority of chronically mentally ill are shuttled in & out of jails & prisons where care is primitive. More expensive meds are about prohibited to prison/jail inmate patients. Psychotherapy is rarely if ever available & limited to "favorite" inmates. I worked in prisons also, for 10 yrs. part-time.
Deinstitutionalization was an unadulterated blunder, more like the Iraq invasion.
Yes, bring back "asylums." Reopen closed state mental hospitals. Build more, a lot more.
Cost is the obstacle. One way or another find money, as money for social security & Medicare.
29
“Deinstitutionalization was an unadulterated blunder, more like the Iraq invasion.”
Yes, and for all the same reasons. It was driven from the top by elitist ideologically motivated intellectualizers who overestimated their ability to predict and control results.
5
I grew up in Topeka KS. We had THREE psychiatric hospital there: the State Hospital (which was probably pretty bad), the VA Hospital Psychiatric unit, and for the wealthy, the famous Menninger Clinic. In fact, the staff at all three was pretty much the same bunch of psychiatrists or psychiatrists in training at the Menninger School of Psychiatry.
When I was a freshman at Washburn University. students in my Psych 101 class were asked to volunteer to see an assigned patient on a weekly basis at the VA Hospital. It was only a few blocks from my house, sounded interesting, so I signed up. My patient was a woman who had been there for many years. No one had visited her in many years, either. She was schizophrenic but had lucid moments when on her meds. I visited her weekly for about 8-9 months. Sometimes, she could carry on a conversation, other times she babbled, still other times she paced in an agitated manner. She was on a locked ward and we were not allowed to leave the locked visiting room.
I learned little about her other than that she had a daughter who had not seen her in over 20 years. She also told me she had at one time had a very bad drinking problem. I imagine it was a result of "self-medicating" her schizophrenia.
I cannot imagine this woman living on her own. She would undoubtedly have become a street person. She was a very sick woman and unable to care for herself. I'm sure she was released. I wonder what happened to this poor soul.
28
You have a generous heart, India.
1
Ideally we should have a coherent continuum of care with humane long term hospitalization for those who require it. Decent halfway houses, board&care homes etc. oils help structure out patient treatment. Intractable violence- even if driven by psychotic terrors is not well served by minimal containment.
Of course most lone wolf mass shooters evade all care and families should have stronger resources to enlist when scared of behaviors that fall short of police criteria to hold.
6
Is any one who says we should all have guns of all kinds in homes, churches, schools and on the street not mentally ill?
12
Here is what I know:
It is cruel to leave those who cannot care for themselves on the street.
If that means some sort of institution, even if against their will, so be it.
27
So, Donald Trump wants more asylums. Is this before or after he and the Republican Congress successfully get rid of what's left of the Affordable Care Act and Medicaid??
18
The mentally ill have always been among us. Some can lead happy, healthy, and productive lives with proper intervention along with lifelong access to outpatient care. Others will never be able to care for themselves and need a safe place so they don't end up on the streets. We could do something about this issue but we would rather rely on incarceration than care.
The expense factor is always used to justify why we haven't done more. If we weren't spending half our GDP on the military complex perhaps we could afford to take care of our mentally ill. Our priorities as a nation are skewed against taking care of the least of us.
45
I once worked as a social worker with a charming 5 year old boy who was already a sexual predator. In foster homes he would sneak into other kids rooms at night. His last foster mother was loving and elderly. She lay awake at night listening for him to sneak into other kids rooms. She was a heroic and special woman. One day, although he adored her and she him, illness prevented her from caring for him any longer. Thus began a tour of going from group home to group home. I tried to secure placements in residential treatment centers to no avail. They were all afraid for their other residents. There was nowhere for him to go. The sex was his only problem at the time. He needed to be contained in a loving environment where his proclivities could be managed. I retired and maybe I'll hear about him when he gets to prison after a few years of damaging other people's lives.
13
It’s illogical to take a stand against institutional care based solely on the fact that it did not work well in the past. We can learn from those failures and design something new, with better protections for patients’ rights.
This isn’t just about the one-off loners who decide to shoot something up. It’s about managing and treating the chronically ill and the acutely unwell in a way that keeps both them and the public safe. We all have the right to be safe. To feel safe.
The small, ultra-liberal city near my home has become an outdoor, free-range mental institution. An ever-growing population of transients, attracted to the city for it’s generous attitude toward the needy, occupy the parks, camp in open space preserves, use residents’ gardens and parking structures as toilets and safe places to shoot up, or for prostitution. Who takes care of this ragtag population of the mentally ill, the addicted and the (often) violent? It falls upon the park rangers, the police, the sheriff’s department. Park rangers pick up human waste, used needles, bottles of urine (a common thing, oddly). Volunteers too often put themselves at risk, as they step in to fill the huge gaps in care. There area city-run shelters, but many who use those for the meals and bathing facilities will not stay overnight. How does the city address this? It provides a sanctioned, monitored place for transients to camp. It even provides taxi service.
Who is sane in this scenario?
53
Where are the norcal billionaires in this? Rather than giving another stadium or another 100 million to Stanford, why not build asylums and leave the money in trusts. That would not only relieve teh suffering of vast numbers of people, but also help the immediate familes of these people who, without help, have their lives completely destroyed.
8
Jennifer Mathis is like the anti-vaxers, resolute in her beliefs no matter how wrong she might be.
By her arguments we should also do away with nursing homes, hospice centers, and other group quarters facilities since these all exhibit cases of abuse.
The current system of having the mentally ill live on the streets is the worst possible solution.
62
Surly those who say no to mental institutions have a plan for what to do with the homeless sometimes aggressive people who live in tents scattering cities around the us? People don’t have the right to camp out in public streets and outside of private businesses. In Portland homeless have caused businesses to vacate properties, is this cost to normal people justified in their eyes?
They refuse to be treated for illness, beg for money along highway off ramps and are a danger to public health. Would they not be better off in an institution which treats them? Not an institution of the 20th century but one based on successful models like those in Europe?
Honestly its a no brainer, it would be a great comfort to know if i end up homeless and mentally ill that i would be supported by institutions which would treat me instead of letting me rot but with my freedom to do so.
52
I am with Trump on this. Prison is not where these people need to be. I hate Trump but agree here.
30
I'm a retired family physician with training oriented to prevention.
There are two preventable causes of mental illness: traumatic brain injury and early childhood abuse and/or neglect.
We could really focus on preventing TBI and even if we could prevent half of it, we would prevent a lot of mental illness.
But the real money saved would be in prevented unplanned and unwanted conception. Individuals and families that want a child and plan for a child are much more likely to be able to provide a safe and nurturing environment for that child. Persons with mental illness or addiction problems often have trouble managing to appropriately care for their children. Economic challenges cause stress and chaos all by themselves: and the expense of child bearing, rearing, and childcare, can multiply the stress.
Cheapest way to decrease mental illness long term is to support family planning and medically appropriate contraception for every woman in the U.S. who wants it. We have really really could contraceptive choices now: we should use them.
72
Really? “We” should use them? I live in a state where “contraceptive choices” are freely available (and some are free to those who cannot pay). Yet there is no shortage of unwanted pregnancy. The ugly fact is that a lot of people who should not be making babies do so anyway. And that is true across the socioeconomic spectrum.
I know a family who adopted the sixth child of a young, single woman who began having kids at age 15. All had different fathers. She was convinced to give up the last child — who had some medical issues when born — through a concerted effort by social services and some really pushy hospital nurses. No one barred that mother from accessing contraception. No one could force her to use it.
4
How do we help prevent TBIs? My mind went immediately to football, but women certainly experience TBIs as well...
2
While most would agree that greater inpatient capacity is needed, there must also be greatly enhanced outpatient care. Almost all inpatient admissions end. When patients are discharged, continuing care must be provided or stability is lost and people suffer.
12
That was the lie of deinstitutionalization - that the money would follow the patients into the community. It never happened and here we are. Many of those people could be helped with supervised independent living but the government doesn't want to pay for it and never has. The other piece of this story is that we are talking about fixing the people who might abuse gun possession and ignoring the fact that, regardless of their mental capacity, they could not murder masses of people with anything other than an automatic weapon to which no individual outside active military should have access. Solving the mental health issue would not solve the mass killings. Not all the shooters would have been recommended for hospitalization prior to the act. We need to do both - serve the mentally ill in a humane way AND ban private ownership of guns whose only reason for existing is the rapid destruction of multiple human bodies.
5
Not either/or. Both/And. We need more beds in better treatment centers and more community systems of care. Get money from the Federal Government, but get communities to figure out how to deploy the funds. Don't go back to anything. Move forward with the good ideas that were never implemented. We have to give these people an alternative other than jails and prisons.
19
The federal government is in hock to its eyeballs and this was always a state responsibility. Why do the states need to run to the federal debt printing machine to meet its moral responsibilities? Louisiana even operated it’s state psychiatric hospital through the civil war. It is just a matter of our state legislatures deciding to put the most helpless people of society who can do nothing for them in return in line ahead of the other pork seekers lined up at the legislative session.
1
As the debate brews about whether asylums should be reopened and psychiatric beds increased, there is no conversation about the role people with mental illness are capable of playing in their own recovery. There is also little recognition that hope exists for this population to achieve fulfilling lives that include working, going to school and contributing to society.
As a community psychiatrist specialized in schizophrenia, I have spent decades approaching patients from a motivational rather than diagnostic perspective. As a result, I have witnessed them move beyond the management of their symptoms to the realization of their life goals.Rather than reopening the costly and often time inhumane asylums, we must invest in Community Systems of Care with social interventions in the areas of employment, education, and housing. A recent NYU study confirmed the efficacy of this approach demonstrating a 21% reduction in Medicaid costs among members of Fountain House a 70 year old New York City -based community mental health program.
Ralph Aquila M.D. Medical Director Fountain House/Sidney R. Baer Jr. Center
33
If success rate is 100%, then teach others. If it is less than 100%, advise us what to do for those who do not respond to your methods.
2
The fact of the matter is that the streets of San Francisco are overrun by mentally ill people who have no where else to go. It is a huge problem - whole neighborhoods are worse than third world slums. SF is the city of choice for many because it is tolerant and never too cold. It is killing the city, which cannot cope with the mess.
58
The amount of violent, insane behavior I have seen on the streets of SF scares me in a way I have never experienced in other city up to this point in my life. I've had to literally run across the street multiple times to avoid being accosted by a clearly deranged homeless person. Yet the city of SF remains unwilling or unable to do anything about it.
6
Wouldn't it be nice if the Tech Giants (who are making so much money by sharing our information) put aside 1% for the care of the mentally ill in the city that they love?
10
The city, which is rolling in cash, should open some asylums. Give these poor people asylum.
5
Mental health is part of the generic health care debate. Are all Americans entitled to affordable, quality health care? If so, that includes short- and long-term behavioral (i.e., psychological) and psychiatric (i.e., biological) health care.
16
The related debate is going to be with gun control. Theoretically, both the NRA and the gun control activists agree that the "mentally ill" should not have guns. The fight is going to be defining how mentally ill a person has to be and who decides if someone fits that standard.
8
It is important we provide care for the mentally ill, using community care, and when necessary, inpatient care - hospitals.
But, as this article suggests, the elephant in the room is cost. How are we going to pay for the necessary care? America is a wealthy country, but even our resources have limits.
Reducing military spending is likely to be part of the solution. But there are people and nations in the world that are not good, and that would like to do this country harm. Maintaining the ability to defend ourselves is a necessary evil.
Which leaves the difficult issue of how to fund a much needed social safety net.
5
We are not spending only to "defend ourselves." We are spending to get involved in wars we should never have entered and will never win-now we are building up our presence in Afghanistan again...
7
Whoever researched and wrote this piece left out a major, perhaps the major, missing component of this conundrum- an acute, critical shortage of psychiatrists.
Build all the mental health facilities budgets will allow, but this is not akin to building hotels or homeless shelters. Psychiatrists, in recognized short supply, and other mental health professionals, do not want to practice in institutions, consistently preferring and choosing outpatient practice and delivery. Even then, many are professed "pill dispensers", as most psychiatric illness, inpatient or outpatient, is today managed by administering psycho pharmaceuticals, with too little professional human interaction.
At least in institutions, patients are compelled to take their meds, where in outpatient settings many, often most, do not so continue. Thus the set up for more social and societal problems, as these individuals cause more problems for themselves and others.
They often present to emergency departments, via law enforcement or family, and we are compelled to make difficult, too quick evaluations and dispositions, not the best for patients or society at large.
Trauma/ED physician L.A.County
35
Psychiatrist began leaving institutional practice when they were demoted from being in charge to narrow functionaries, just another member of the treatment team. They are physicians first and feel an ethical responsibility for their patients care. They don’t want to work where they can not discharge that responsibility because 90% of the decision making is left to “policy” or the “team”.
4
I hope this idea isn’t supposed to solve the gun problem in the U.S., because the gun problem will only be solved with strong gun regulations. What asylums will solve is the immense problem of the homeless who’s mental illness refuses treatment. Yes, there is such a thing as people who are not able to take care of themselves. Only an insane society would argue its OK to let such people to do as they please. It’s like believing a two year-old can feed, bathe, shelter and clothe itself. Enough of this nonsense. It is the one issue I completely disagree with the ACLU about. Closing the asylums in the ‘80s was a misinterpretation of civil rights, just as the NRA totally misinterprets the Second Amendment.
36
Completely agree with you. While the ACLU’s position is noble, it completely ignores the reality that the severely mentally ill lack even the minimal levels of traits we associate with adults: judgment, impulsivity control, accurate perception, etc. It is fundamentally cruel to them, and to the rest of society, to have them wander our streets.
7
If someone refuses to take her meds and episodically hallucinates or has a psychotic episode, you can put her in the hospital for treatment. And when the medication takes effect, the patient is then competent to make her own medical decisions and is discharged to the family for another cycle.
We need to consider what happens too often in real families who lack the resources to manage the problem child. Sometimes the legal rights don't mesh with the medical realities.
40
in washington state we have a total of 800 beds for the entire western part of the state ..most of them are filled police holds ..so unless one commits a serious crime they will wait about 7 years for a bed unless they can pay cash or have insurance for a private hospital
1
Don’t know exactly what Trump has in mind, but it’s worth remembering that Ronald Reagan pulled the federal funding plug on these services in the early 1980’s. States and cities were unable to fill the gap, leaving these people to wander the streets unattended, homeless, and without proper treatment.
48
I only recently learned that Reagan completed what Kennedy started - and was mentioned in this article: "In 1963, President John F. Kennedy initiated the Community Mental Health Act, intended to end institutional abuses and create a system of community-based care."
3
State psychiatric hospitals were never funded by the federal government. Reagan didn’t cause this problem any more than he caused Herpes.
2
The debate is really only about who will pay for the needs of the commons.
The GOP has decided that Government is an evil necessity that must be deprived of all funding to do anything but National defense.
Healthcare and Psychiatric Care and Long Term Care do not fall into this convenient paradigm.
What will eventually happen is that we will be a Class Society, in the way that Britain was 150 years ago and that India was 75 years ago.
That is what the Republicans want: Untouchables and Outcasts - Out Caste - people in America. I hesitate to write people. Because the Republicans do not think they are.
Given Republican economic determinism, those who earn little or nothing are not deserving people and
Republicans believe they should not vote by virtue of their poverty and lack of land.
What a country
22
Your characterization of this as having any relation to political partisanship is utterly devoid of any foundation in historical reality. Your comments about class as it relates to this problems are equally off the mark. Even the slave states put more of their state budgets into operating state psychiatric hospitals in 1860 than they do today ( they even remained open through the war).
As a criminal defense lawyer, I can tell you with 100% certainty that we have never stopped institutionalizing the mentally ill and that there are some severely mentally ill people for whom community care will never work. Trust me, you don't want them on the street -- ever. A small percentage of them aren't stable even when medicated, and they won't voluntarily take their medication anyway. Prisons fail these people because prisons aren't hospitals, but that's the only place to put them. So, yes, we do need more institutions for the mentally ill. It boggles the mind that an entity as venerable as the Bazelon Center would reject the idea outright. They don't have to be like the institutions of the 20th century, do they?
120
The track record of mental health in the US is inadequate investment. the early psychiatric hospitals of the 19th century quickly found themselves of orders of magnitude more patients than they were designed to serve. Understaffing was not a 20th century phenomenon--it was present almost form the start. Community mental health has never been adequately funded and knowledge of what works has never been implemented widely. it's true that some people do not benefit from medication or community intervention, but simply building new facilities won't solve the problem if that are not adequately sized and staffed with integration to adequate programs in the community--getting a real commitment to this agenda rather than a quick fix that won't be adequately supported in the future.
4
Exactly. Look up the case of Charles Anthony Edwards III, a man with a long history of severe mental illness, who in 2012 randomly attacked and stabbed a woman to death in Santa Cruz, California.
1
Hey those are my sentiments exactly. I don't know what the % would be, but for some folks there are only two destinations if there are no psych wards: prison or the morgue.
7
Discussing mental health treatment as a way to halt gun violence raises more questions than it answers. What practitioner can predict who will or will not become mentally disturbed? What level of mental health is required for gun ownership? Which medications can a person use and still bear arms?
Clearly, Trump's proposals are inadequate to stop the violence.
8
Shhh ... Trump's idea is getting people talking about Residential Care for the Mentally Ill. If he thinks it'll prevent gun violence and that it's a valid substitute for enforcing gun control, don't tell him!
It's true that there are some that need to be contained, both for their own good and the public's.
I think that Trump should give up going to Mar-a-Lago and spend his time checking to see which asylum is the best.
34
When is America going to embrace the obvious?
Most mental illnesses result from the maltreatment of children. When kids do not get what they need developmentally, or when they are traumatized, their minds do not form in correct ways. Their assumptions about "life" "people" and "me" are skewed by the circumstances they have been brought up in.
We may need more asylums but only if we take as a given that people continue to mistreat kids. As Dr John Briere of USC said, "If we could end child trauma, the DSM would shrink to a pamphlet in 2 generations."
Why is the focus adults? Let's PREVENT mental illnesses by raising children in compassionate, attached ways.
38
Megan, Where is your evidence for this overlybroad statement? I don't believe you can substantiate this. Some cases, yes. Most? No.
8
Even if it were that simple (and it is not), not all childhood trauma can be prevented. Parents die in accidents, from cancer, etc. on a regular basis. Children lose siblings in the same manner.
6
And meanwhile?
The notorious "Willowbrook State School" was not a mental health institution, as the caption under the picture says, but rather a NYS institution for developmentally disabled individuals. This article does not seem to distinguish between the mentally ill and the developmentally disabled, thus perpetuating an unfortunate stereotype in the minds of the public. Developmentally disabled people usually have life-long deficits which require special training and supports, unlike the mentally ill who may require only a few months of assistance before they can function autonomously.
94
Unfortunately, long term treatment is a need. Mainly because the severely and chronically mentally ill have a tendency to go off their meds repeatedly. A few months might stabilize someone with repetitive suicidal ideation, but it won't fix Bipolar I, Schizophrenia, or other recurring psychotic illnesses. Not all person with these disorders need long term care, but there is nowhere for those who do, to go.
13
it was also not a school
6
If you are schizophrenic you are not schizophrenic for a few months. You are schizophrenic for life.
Have you ever heard a schizophrenic in a paranoid state? They are going through complete and utter terror. They feel that for days and hours at a stretch. It is unimagineable human suffering. They Iike to be doped up when that happens. Who wouldnt. The problem is when they no longer appear psychotic they are released, stop taking their meds, stop coping and then get paranoid again. No. They need to be institutionalized, for their sake. But these institutions should be run by public organizations with good controls and transparency.
3
Whether we admit it or not, we're still warehousing the mentally ill, although, now the warehouses are the streets, jails and assisted living facilities.
88
I wish the rest of the country would stop using SF as the warehouse for their mentally ill.
7
Spot on.
This piece fails to address the most important issue: consent.
Involuntary hospitalization is a form of incarceration without crime or conviction. And in a way, it is worse than prison, in that it empowers experts to deliberately tamper with your mind.
It's quite possible that a form of asylum that serves only people who want to be there, only as long as they want to be there, could help a lot of people. But increasing the capacity of institutions that people are forced into poses a threat to anyone who might be labeled mentally ill -- which is a lot of us.
10
Many of the worst of those affected by mental illness do not have the insight to make sound decisions that benefit themselves and their safety and health....basics such as choosing access to shelter and food over living on the street. Until you have seen the utter lack of being able to make a choice that facilitates survival/ basic human needs being met, you don't understand how lost those individuals are. We don't allow those with Alzheimers or other dementias to wander the streets, making their own decisions about their care. Likewise, we should not grant to those without insight (a dementia of sorts) into their dire mental conditions the ability to choose to endanger themselves (and possibly others).
21
I suspect you haven't known a lot of people with severe schizophrenia, cutters, persistent suicidal impulses and other extreme illnesses. Yes, some do need to be committed involuntarily. When patients don't have enough function to survive on their own, it's inhumane to leave them to the streets. An equivalent would be sending a 4-year-old out to fend for himself.
6
I have witnessed first hand an example of this abuse. A close relative of mine with suicidal ideation and an attempted suicide was seeking treatment, but was involuntarily committed and taken to a mental health facility by police. The committal law of that state required 2 elements: that the individual was a danger to him herself or others AND that they refused treatment. My relative knew that he needed treatment and wanted it.
At the judicial hearing, his lawyer pointed out that he was not refusing treatment. His treating psychiatrist, a respected member of the mental health community, lied on the stand and said that my relative was too ill to consent to anything. (And yet behind the scenes he was trying to get my relative to consent to ECT treatment.) The judicial hearing was no more than a rubber stamp to the psychiatrist's verdict.
Obviously, there are many severely mentally ill people who are clearly incapable of making decisions on their treatment. But there must be effective safeguards to protect the right of consent for those who are capable of doing so.
4
One has only to look at the so-called "effectiveness" of state hospitals in the 1960's and 1970's to see what a disaster large state "mental health" institutions have been. Moving treatment to the community level has proven to be very effective for the vast majority of those suffering from debilitating mental illness. These are the clinics and physical health institutions that need to be supported.
10
Point well made. But for the small percentage who they have not been effective for, we need longer term care options.
5
Moving treatment to the community level has proven to be disastrous. In many places there is virtually no treatment available at all. Lawyer Tom: you don't get out enough.
7
There is reasonable data and experience to support the role of complementary services without taking a dichotomous stance. Ask any provider within the mental health system on the front lines--they will verify the lack of acute care options. We also know enough to establish services incorporating more intensive/residential program vs. intensive outpatient. (Some good European models).
(Given apparent blocks on commentary from one who has indeed worked in the field-- will need to post up on twitter to workaround this communications barrier)
14
Just an aside here: I doubt that the New York Times would block the comments of such a well- qualified professional, especially one so knowledgeable on the topic. There may be some technical glitch causing a problem. I had few comments published while using my old computer. Now my comments are more often published. Or, maybe the Times has hired more people to scan the comments, now that they have many on-line subscribers.
I hope you have seen that they DID publish your comment here.
2
We have had good models of full range of services here both public and private. Integrating outpatient, residential, partial hospitalization, open inpatient, acute locked inpatient, and long-term inpatient with a full range of therapies. Results were excellent. I worked in some of them. That was a lifetime ago. They no longer exist because this society just doesn’t care to pay for them. Football stadiums and sugar subsidies are more important objects of public handouts.
3