From the article: "Today, less than half of all adults suffering from mental health conditions receive help, and mental illness is the leading cause of lost workdays in the United States, costing about $193 million in lost earnings a year."
$193 million in lost earnings is substantial, but not overwhelming. I was surprised by this small amount. Assuming approximately 18% of the approximately 150 million working Americans suffer from mental illness (as per cited American Psychiatric Association article), those 27 million individuals lost $193 million, or $7.14 each. Perhaps the $193 million is an error. Perhaps it is $193 billion, which would be more reasonable when discussing a problem of this magnitude. Any thoughts?
1
Like Trump would know mental health. He quacked for years that his predecessor was from a foreign country.
Actually, the Trump White House would be Outpost #1 for most people who value truth, justice, and the American way.
Maybe if some other country like Denmark or Sweden ran the program.
I can't say for anywhere else, but I've encountered an alarming number of people getting so called degrees in various forms of religious counseling. The most disturbing one and recently too is someone who was proudly announcing their graduation from a program in "biblical counseling." Many of the mental health resources here reference or allude to spiritually informed services. Meanwhile, there are only 3 or 4 fully licensed psychoanalysts in a city that proudly calls it self one of the 10 to 15 largest cities in the country, varying on who is doing the counting, the larger claims, of course, coming from the more religious populace. it's frightening that the same people who brought us trump, repeal of gun laws, and making abortion unavailable are making such emboldened strides into mental health care.
2
I've seen a dear friend with schizophrenia fall through the cracks of our mental healthcare system. She spent months cycling through brief hospitalizations, homelessness and incarceration as a result of the reasons listed in this piece - commitment standards were too high, a continuum of care didn't exist, and insurance parity isn't well-enforced.
After years of this, she was finally stabilized as a result of the criminal justice system. She was in a court-ordered assisted outpatient treatment program to avoid incarceration for a violent incident driven by her untreated psychosis. When she didn't follow the terms of her assisted outpatient treatment diversion program, she was involuntarily committed to a psych ward for 2 weeks.
Her time in the psychiatric unit was certainly unpleasant. She didn't want to be there, but this was when her doctors finally struck the right balance with her medication. The support of her AOT diversion program kept her on track when she was discharged. She dislikes her medication's side effects, but she hasn't been homeless or arrested since being in treatment. She understands now that her psychiatric treatment is far better than being back in jail and is now compliant, safe, and healthy. She's even returned to school. Fortunately, her story has ended less tragically than many others' do.
6
I see many, many mentally ill homeless people every work day, in the East Village of San Diego.
The problem is a Federal problem, because we, as modern nation, should take responsibility in caring for these people because there will always be a percentage of people who incapable of caring for themselves.
I know the concept of "warehousing" mentally ill was the downfall of the old system. We need to think of new ways to care for these people . Perhaps aligning large regional hospitals to oversee their care, using their systems but with Federal sponsorship.
5
Yes, let's do bring back asylums (by whatever name) to house and treat the mentally ill. Because the mentally compromised are a particularly vulnerable group, the system will need rigorous and independent regulation. The most abusive of mid 20th century asylums were a better environment than living under a highway bridge and slipping into drug addiction, sharing needles under perpetually unsanitary conditions.
Don't tell me that the abuses of the past are unavoidable. They are not, and avoiding them is a simple thing: just fund the mental health system adequately from responsibly-designed tax collections and apply accounting oversight.
8
During the Kennedy era deinstitutionalization happened and smaller mental health, even locked ones, grew. Then Reagan happened and the smaller, electric facilities were closed, many thrown on the streets or institutionalized in the large facilities. Mad in America is a great book to understand how progressive countries treat mental health issues by surrounding the person with a lot of support and only using medication as a short term solution.
3
Who will pay? The Community Mental Health Act failed because of lack of government funding for treatment and facilities. Insurance companies do not want to foot the bill, though I recall a time decades ago when they were more likely to pay for the extended hospitalizations some people need. There needs to be massive shifts in federal laws and policies to respond meaningfully to this problem, and if anything the country is moving in the opposite direction. Recent tax cuts will precipitate budget crises in the future, and it looks as if it will be increasingly difficult to maintain much less augment social services. The editorial is to be commended for raising the issue, but the solution requires a political will nowhere evident in public discourse. Neither the Left nor the Right appears willing to commit itself solely to broad measures designed for the public good. If you do not believe what I've said about the Left, look at recent stories about the foundation named for Paul Wellstone, the Minnesota senator who the Mental Health Parity Act was named for in tribute to his efforts in this area.
4
After travelling the world, my sister, who suffered from terrifying hallucinations, ended up in France.
There, she was finally hospitalized for almost a year. Then she was able to rent an apartment with a friend, all while spending 8 hours a day at the psychiatric facility where she had been for the previous months. After a year like that, they managed to reduce the number of days she went there, and then finally helped her to create her own business and work part-time. That then allowed her to reduce her prescription drugs (and their horrible side effects).
ALL of this absolutely CRUCIAL aid has been paid by the French government, for a citizen who isn't even French.
The constant goal of the team taking care of her at the hospital was to get her out of there as soon as possible, all while accepting to keep her EVERY minute that she still needed it.
To me, that psychiatric facility, together with the French mental healthcare system, truly saved my sister's life, so I'll be eternally grateful.
Today, there's still ONE thing lacking though: because of the anti-depressants and anti-hallucinations drugs on the one hand, and lack of training on the other hand, she remains cut off of her emotions most of the time. So her capacity to become truly happy remains limited - even though this kind of training already exists in the US (see Julie Simons, for instance).
So WHAT are we waiting for to finally do the same thing here, once we're talking about America's "greatness"??
7
I am a medical student who just finished third year rotations, which included a month at a state-run psychiatric facility. When I first started my rotation, I was slightly appalled by the entire situation. It seemed so archaic to segregate an entire group of people due to a medical illness.
During my time there, my views on the system began to change. Many of the patients were the unwanteds from society. They had no safe place to go and if not there, they likely would have been in prison or homeless. At least at this hospital, they were safe and had a community. They had a voice in their medical care and were offered extensive therapy. While no institution is perfect, my experience there was positive. I saw how a very sick, mentally ill person could transform into a productive, stable individual when given the right environment and care.
10
I’ve been so fortunate to receive government funded psychotherapy in Ontario, Canada. My therapist told me about a study in Germany which showed that state funded healthcare always works out better because the average individual will never save enough for their own healthcare. I think mental health is an even more salient aspect of people not seeking out healthcare if it’s not publicly funded. My uncle had a nervous breakdown in university and treatment back then was a labotomy. So sad. I’ve had such a full life. I am truly grateful.
5
The same goes for my sister living since 10 years in France ...
Asylums were, originally, designed to be places where one went to be treated for any host of mental disorders and then returned to live in society. Unfortunately, they evolved to accept people for whom life in society was too overwhelming and, therefore, not likely to ever leave. As they matured, these institutions became increasingly populated by those for whom returning to society was not possible. Many of these institutions became de-humanizing and horrific, despite the efforts of the many well-meaning people who worked very hard to care for the needs of each individual.
Had the promises of properly staffed and funded community mental health centers eventuated, the impact on society would have been, overall, positive. While there will always be exceptions to any institutional effort, more people would be able to function in the community.
And isn't that the most important goal?
I work with people who have been designated severely mentally ill. They have many needs and often have no resources to meet their needs. The wealth in this society is being channeled into supports for corporations and the wealthy. If people had stable decent housing, a good healthcare system, access to safety and protection from abuse and violence, and a sound progressive educational system, we would have fewer mentally ill people and more services to support those who are struggling. Ultimately we get the society we demand. How important are the most vulnerable in this society to you?
6
Will give this a try but we have been plagued with this very difficult and complex matter for decades. With over 40 years of caring for psychiatric patients, I have seen many, many sides of this issue. First of all, inpatient hospitalization is almost non-existent compared to years ago. But even in the 70s-90s, working in urban psychiatric crisis emergency rooms, we never had the beds available to hospitalize longer than a week or two. Thousands were sent back out to the streets to fend for themselves unless we were lucky enough to secure a bed for the night at the Salvation Army (God Bless them). Cut wrists, overdoses were never enough for admission. Move now to the large urban jails where many of those just seen in the ER the day before, were arrested and jailed. We dealt with fulminating, overwhelming psychoses among the inmates for months on end. Estimates well over 40% of those incarcerated have a major psychiatric diagnosis. Outpatient services are grossly limited and inadequate and have been so for decades as well. Move once more to the mentally disabled living in group homes. Once out on the street, which of course is their right, they are subject to all types of abuse--robberies, beatings, and sexual abuse. In conclusion, do we need long term care facilities---this goes without question. There are thousands of people who need this level of care. We just are a society that has not been willing to insist upon it---so sad....
6
What I often wonder about is why having a physical is a standard medical yearly practice while having a mental health yearly checkup is unheard of. This is something that should be routine, for youth, adults and elders. It's way past time.
2
For at least the last 4 or 5 years I am given a screening exam for depression at every yearly exam and sometimes more often if I haven't been in for a number of months. That IS routine care for all adults and if your provider isn't doing this it might be time for a change.
San Francisco is spending over $300 million per year to deal with 10,000 homeless people--a major portion of whom would be covered by all the pious preachings in this article...What's missing here is any semblance of a cost estimate to enact these reforms. It's also worth noting that, at least in San Francisco's case, the hundred of millions expended have not made one whit of a difference.
4
The problem of providing decent appropriate long term residential care for chronically mentally ill people is complex. Unfortunately, one size doesn't fit.
The liberal ideal of deinstitutionalization was simplistic & naive.
In an age where easy substance abuse, homelessness and jammed prisons fail to sort a huge variety of folks unable to safely care for themselves.
The cost of dozens of brief acute hospitalizations is astronomical and untherapeutic. Part of mental illness is impaired judgment, poor self-observation capacity and destructive impulsivity.
Yes- volatile people should not keep guns and concerned family members should have a simple mechanism to initiate a home visit by trained professionals which may not require involuntary hospitalization.
On the other hand, a person who has been unable to function with out patient support, unable to stay out of trouble, tormented by chaotic delusions...that person would probably benefit from longer term placement.
We do not cure severe mental illness that often; watching tent cities spread in big cities is a terrible alternative. Civil life should not be sacrificed for cruel notions of personal 'freedom.'
4
Right? Because if the ~1% that are insane were locked up they would not be out shooting up schools to get celebrity, big Pharma would not be able to make trillions 'just in case' doping up half our population, and above all the democrats would be denied the votes of their most loyal dependents.
1
When the institutions were closed down, too much of the rejoicing was about saving money while some rejoicing related to ethical treatment of the mentally ill. At the same time, too little planning and spending was, and is, dedicated to care in the community of those in need of mental health services. The profound ignorance of people like Donald Trump is no help at all.
4
Right now county jails are serving as the alternative to the old psych wards that were shut down in the 80s. People with schizophrenia or bipolar disorder or some other severe mental illness occasionally will do something violent, like stabbing a family member when they are delusional, and they are taken to jail if they are lucky enough to avoid a violent end themselves. Some self medicate with illegal drugs. The jail is not equipped to deal with them and they usually receive no treatment to speak of for months and no one will bond them out. It needs to be easier to forcibly commit people to a psych ward, to keep them for a longer period, and to force them to take their meds. All of that requires money for more psychiatrists, psych wards and social workers to check on them and health insurance to cover mental illness.
3
The faux-compassion the left pushed by closing mental institutions has manifested in thousands of mentally ill, homeless and harassing the rest of society. Most are supposed to be taking medication but refuse.
As always, the unintended consequences are worse than the original problem.
4
Trump is over 70 yrs, and no one I know has petitioned to have him institutionalized. Go figure.
There have been a few comments on the bad effect of drugs given people who has been committed. If you have mentally ill people in your neighborhood there is a pretty good chance that they are already on drugs.
Funding custodial mental health care is much more about assuring the possibility of quality of life than it is about preventing crime. Many of the homeless are schizophrenic and unable to help themselves when they are not properly medicated. A feature of the condition is the inability to believe they actually need the care they need which causes them to spiral downward when left to their own devices. They need a stable custodial living arrangement where someone makes sure they are taking their meds, eating right, not drinking or drugging, socializing, and getting proper medical care when needed. Under these conditions most schizophrenics are able to live semi-independently in their own apartments, hold down jobs, and have meaningful relationships, especially maintaining family ties. For the sub-group that can't abide this, often the result of drug/alcohol addiction, more restrictive custodial care options are needed - but not in a prison setting.
Crime prevention is a drop in the bucket of the need for mental health care.
3
My oldest has schizo-affective disorder, won't take meds, won't stay away from any recreational drug offered, won't even stay home, and is too unstable to be trusted at home anyway. What I wouldn't giver for an asylum rather than being under constant stress waiting for that inevitable phone call from a hospital or police officer. So far those calls have been for confirmation that there is a mental illness, but how much time do I have before I'm asked to identify the body? Again, what I wouldn't give for an asylum as an alternative to that.
18
As a psychologist for 30 years, I can tell you that the "communities" do not want their mentally ill citizens back, and one of the biggest barriers to community based care is compliance with treatment. Until these are addressed, it's not going to get better.
10
I don't know that this is such a bad idea. With proper oversight it would certainly be better than people being in prison without treatment or homeless. Of course there are better solutions for a lot of people but it would actually be an improvement over the status quo at least in general.
4
Has anyone on the editorial board worked in an extended or long term care institution for the mentally ill? Or, cared for their needs on eight hour schedules during the day and night time? If not, be sure to include those who have, before determining what is or is not "crazy talk."
Many of those "Asylum" institutions were self sufficient running homes where patients were taught activities necessary for subsistence. Most conditions could be managed toward discharge when the patient was stabilized. Unfortunately, some returned for newer treatment protocols when their diagnoses were chronic.
What is needed is more Government funding for improvement in the diagnosis and treatment of mental illnesses.
Homelessness of the many who require supervision and care is a cruel and heartless alternative.
10
There is a place for brief hospitalization designed to return a person who is exhibiting anti social or suicidal activity to the community. In no use should anyone think of that hospitalization as a time - unlimited lockup. We don't have "asylums". We have hospitals. The purpose of the hospital is to ameliorate the illness and restore to health. Not to "Lock 'em up and throw away the key," just because that's easier and cheaper than fulfilling the goals of an adequate multi-level community mental health system. We most assuredly have never reached that point and unfortunately, our American society just doesn't care enough to spend its resources to make it right.
1
My father was on the board of a community mental health service created as deinstitutionalization occurred. He commented that everyone else on the board took it as an opportunity to fund services for what he called the worried-well, such as counseling for kids whose parents were divorcing. Even the mental health professionals on the board had little experience with the illnesses of the people about to be released.
At no point did the group ask how many people with what diagnoses were expected to be released into the community or what services they needed. I don't know if my father ever managed to get the answers to those questions.
The community mental health services got highjacked because those shut away in asylums had no advocates but there was a sizeable constituency for services for people with far more mild problems.
5
I was a medical student rotating a clerkship at a state psychiatric institution in the late 1970's. The patients were clean and well cared for. There were gardens and bakeries that they could work in. There were beautiful grounds. There was a forensic unit of dangerous patients where we were not allowed, a student had been murdered there previously. It was during this time that the edict came down that these institutions were going to close, and the patients be released into the community. I remember thinking that were many I could not imagine in a community setting. So they closed. And one of the problems is the community centers did not materialize. And we need not just outpatient community mental health centers, but housing that would include care for many of these people. They can not care for themselves. They can not take medication daily, they are not capable. Fast forward years, my sister had a daughter who was diagnosed as schizophrenic in her 20's. Now 40 years old and lives at home with my sister. She has been through multiple hospitalizations every year, " stabilized" and released back to my sister. There were so many times my sister could not handle her, and she had nowhere to turn. The hospitals never had any suggestions, or homes for her. They told her if my sister did not take her back, they would give her a ticket to a homeless shelter. The amount of ( public) money spent on her hospitalizations over and over is staggering.
14
Prisons are currently our primary mental health care facilities. And they are not asylums. The Cook County Jail is as much a mental institution as it is a prison. Ineed the current warden is a mental health care professional.
See "Insane: America's Criminal Treatment of Mental Illness " Alisa Ross
6
Having worked for several years with people with severe psychiatric disabilities, I want to say the normalizing of their suffering makes the normalizing of sexual harassment and domestic violence seem minor. I know that's a shocking statement, but it's meant to be.
The low status of services and treatment and, therefore, the unnecessary, profound & grinding pain, so many decent and brave Americans go through on a daily basis is a national shame. Like "women"- disposable.
2
About 110 years ago, my grandmother's older sister, aged about 24, who had apparently exhibited no sign mental illness previously, went off the rails after the birth of her second child. She began leaving the baby naked on the ground in cold weather, apparently in an effort to kill her. She also attacked my grandmother, age 14, with a pair of scissors. Before the attack, she warned my grandmother that there was something wrong with her and to go and lock herself in her room. I was never told the details but this great-aunt was declared a danger to herself and others and committed to the state mental hospital in Milledgeville, Ga., where she spent the rest of her life. I never knew of her existence until she died and we went to the funeral, but I have often wondered what would have happened to this woman in our day. Are we more enlightened about mental illness since we jail such people or abandon them to wander the streets muttering to themselves until they do something to attract attention from the police? I'm not defending the state mental hospital, which was certainly no paradise, but it might have been better than what happens to many of the mentally ill today. Ola Mae Murchison Corbin died at I think age 74; from recent statistics I've seen about shortened life expectancies for people with serious mental illness, it sounds like she did okay for a woman born in roughly 1895.
4
Dear NYT. As a physician and a caretaker of a family member with schizophrenia for past 25 years, I can tell you how shamefully wrong and shortsighted you are. Prisons ARE today’s asylums. Discussions should not be if we need long term mental health facilities, but how many and what kind. I will let you decide whatever you want to name those. We need leaders (in all fields) and philanthropists. I guarantee that things will change if some powerful and/ or rich person like the President or a prominent Senator has a son or daughter with schizophrenia at the tender age of 15. That is exactly how we saw changes in last 15 years for patients with Alzheimer’s. Regards, AJ
9
How are psychiatric hospitals "morally repugnant"? Are regular hospitals morally repugnant? If you have a serious physical illness, you are treated as an outpatient when you can be, but sometimes you have to be an inpatient. Why should the same principle not apply to mental illness?
Psychiatric hospitals are regulated just like other hospitals, but perhaps the regulations need to be updated to require better living conditions (given that patients are generally confined for much longer periods) and enforcement made more vigorous.
That said, I don't know how anyone deny that there are seriously mentally ill people living on the streets - and some living at home - who need to be hospitalized for treatment. Furthermore, not all people in psychiatric hospitals are involuntary commitments. Voluntary admission for treatment of depression, for example, should be easier.
What is morally repugnant, and a guarantee of disaster, is to imagine that we can do anything to increase inpatient capacity without spending money - lots of money.
7
Come spend some time in our neighborhood (the Pearl district) in downtown Portland, and you might regard institutionalization as a far more compassionate option. Every day I see homeless mentally ill people in crisis. Raving, filthy, occasionally nude, sometimes aggressive and clearly in need of care. Portland is deteriorating and our Council form of government is not working. There are 70 vacancies in the police department and an epidemic of opioid abuse. But the mentally ill are the most striking. It is a disgrace that we let these vulnerable people live like this. They need supervised care and housing. Just last week, a young man stabbed a NE Portland resident 17 times after he asked him to move his camp (our last mayor stupidly allowed camping as a solution-now there are tents all over town). The defendant wants to represent himself in court and presents with delusions and paranoia - possibly schizophrenic. It is a human tragedy but I, like many of our neighbors, despair at the daily parade of poor raving lunatics who defecate in doorways, urinate anywhere (even feet from public facilities that are available) sprawl across the streets, spread trash and filth around them and who are clearly in the grips of mental tumult. I would guess that at least half the homeless are chronically and severely mentally ill. At least they might maintain some semblance of human dignity and health if we had some form of institutional care. It is just wrong.
20
I might offer the alternative that if the Portland Community Mental Health services were robust enough to offer services equal to the needs of the souls that you are describing, the situation you describe might not be as you describe it and the role of increased inpatient services might not be needed. Many communities and States are now doing just that. The need for inpatient services in well staffed hospitals will always exist, but asylums will never be. What you describe is a general breakdown in services, not only for the mentally ill. Have you considered that if you weren't mentally ill but were forced to live in a setting as you describe, you might very well become just that? It's all related.
2
It's disturbing to see the New York Times framing the case for better access to inpatient care as a "crazy" notion embraced by President Trump. Many patient advocates, experts in our field and even ethicists are urgently calling for more inpatient psychiatric beds.
https://jamanetwork.com/journals/jama/article-abstract/2091312 … …
6
As a mental health professional, I was equally disturbed by this article. I don't know a single psychiatrist who would not not advocate for more inpatient beds.
2
My university roommate developed schizophrenia...and went off her meds each and every term. She did it because she sincerely thought that there was nothing wrong with her - the television and telephone were indeed spying on her, etc. etc...It was the nature of her illness that she did not think that she was sick. The only person who accessed the university's mental health service was me - to find out what nobody had ever taught me: how to deal with someone else's schizophrenia.
Expecting everyone with every kind of mental illness to even access 'care in the community' (assuming it even exists in their community) seems less than realistic.
11
Your last line says it all. We lack the collective will to care properly for our brothers and sisters. Every last impulse is about money. Not how we create an appropriate setting and proper care for those with mental illness. The term itself is lacking in specific detail and thereby "loaded" and fraught with danger. The general population is unaware of the enormous number of people suffering from autism that are just now entering adulthood. There as so few resources for them, that the only safety net is their parents. Most of us are aging baby boomers. The nuttiness part of it all is that getting it done right is no doubt the least expensive solution in the long run. How foolish of me to ask Government to think of the "long run?"
4
Read or watch “One Flew Over The Cuckoo’s Nest”. That’s one approach to understanding. An uncle of mine was committed by his siblings (there were no safe and effective drugs in the 1950’s). After a few dozen electro-convulsive sessions for his problems he had no need for anything again except a place to sleep and institutional food, for the next 40 years. Then there was Walter Freeman who performed more than 1,000 lobotomies in the 1950’s and 1960’s. These “lock ‘em up” ideas come from people who are worried about their property values, or who just don’t understand that our human condition includes many people who have big problems that the rest of us have to bear, no mattter how unpleasant it is. Locking them up out of sight is no answer and it’s just one step better than the Nazi approach.
1
compare this take with that of the correspondent from Portland, then consider the standard of danger to self and others.
2
The American people are so ignorant of mental illness, that sometimes it seems just another trick that madness plays on the whole lot of us. Look, the conundrum is all the so-called solutions have been tried at least once since The Edict of Nantes; none of them worked very well. Seems to me, that at one time, some of Europe’s laws held that being Methodist meant madness, a priori. I don’t have the solutions, but something fundamental must be invoked in order to have meaningful steps for getting there. One idea is to explore the role of the jury in proceedings involving mental illness. Is it acceptable for the jury/judge/magistrates/councilor represent the public conscience in such matters? Because that’s what we have right now, and it is an abysmal failure.
1
God, I remember when Willowbrook was exposed. Remember when the term was used as a threat for bad behavior. When the mere mention of a trip to Willowbrook, or any known asylum - Creedmore, Kings Park, etc - could make a child behave for weeks.
Chilling.
But I'm not surprised a creep like Trump would see them as good and helpful. Its more a surprise he hasn't raised the specter of internment camps, but instead call them by the less PC term; concentration camps.
Oh wait, we now have swiftly overflowing "immigration holding centers" My bad.
From the article; "the 1963 Community Mental Health Act, which was supposed to create well-staffed, well-funded community mental health centers in about 1,500 catchment areas across the country. These centers were supposed to provide clinical care, housing and employment support, and community outreach."
It goes on to say the law was never given a chance. True. But we can bet if such a thing was revived it would fast become as abusive as For-profit prisons. And be staffed by the severely under-paid, poorly vetted, and/or out right sociopathic. Who should be more inmate/inpatient, then care taker.
I have no idea what the solution is to the mental health crisis in the US. Other then platitudes, and the usual more and better funded health care for all.
But I do know that any solution under this WH, with this Congress would be destined an abomination. It would manifest like the days of the Willowbrooks were but only last week.
You allegedly "sane" people elected Donald Trump, so we "insane" people don't put much stock in your competence to help us or anyone else.
2
you seem perfectly fine to me... at least on this front.
what can we expect if electing Trump, and suffering all the degradation he draws in his wake, is not itself recognized as a form of mass insanity?
the Rapture will no more take care of this than it will your absessed tooth.
it can be said that the Trump administration is driving most of us crazy. now, there's a giant well of empathy.
Too often there is the real world vs some ideal the Times editorial board unrealistically pines for.
Yes, the mental health hospitals and institutions of the past were far from perfect, but closing them has been far worse.
The treatment and care models within such facilities can be updated obviously, and for those with severe mental illness, they are often the most realistic solution.
Some people sadly need to be institutionalized. Update the care and be as compassionate as possible. There is a place for these facilities.
And of course tax dollars will have to be spent to pay for much of the costs, but many of us believe such is the right thing to do. As is providing universal health care in general.
8
Dre, “improvements” to those “facilities” are irrelevant, unless people can LEAVE or refuse to enter those places. A cage is a cage, no matter how many bells and whistles you slap on it.
How will we ever keep Nurse Ratched away? No matter how insistent we are on professionalism, kindness, compassion, educational qualifications and humane expectations Nurse Ratched will sneak in, get a job, become an administrator and drive the sane into craziness and the already mentally compromised over the edge. It is too risky. Even seemingly harmless nursing homes are like siren calls to control freaks seeking careers where their resumes ought to alarm anyone wanting to place a relative in a comfortable end-of-life situation. We absolutely need answers in order to alleviate the pain of those who cannot cope with this world. But to suggest that placement within an intensely managed microcosm of this very world is terrifying. Can we not do better for each other than this? The Nurse Ratcheds of this world are too clever at disguising their own psychic abnormalities, often even from themselves, and too invested in persecuting those whose broken worlds mirror their own to be allowed anywhere near an institution of healing, but they will be among the first to apply for a job because in so-called serving others they will burnish their self-image as being more adept at life skills than the inhabitants. How can we let this happen again? Cuckoos nests too numerous to count--much less to fly over.
1
The suggested solutions would be a step towards more humane and effective long term support of individuals with severe mental illness. However, none of them are achievable in the current political climate.
Community placement is a better solution for many individuals--but only if sufficient community supports are available. In order to be effective, community placement must be done in a manner which is both expensive and time consuming. The last 30 years have made it clear that our governments have no will to consistently devote resources to such programming.
It is inhumane to continue to insist on unrealistic solutions, while resisting the expansion of an acceptable alternative--increased availability of inpatient care. Patients and their families are in a sense victims of such idealism.
6
No one wants a return to the bad days - but it's pretty hard to not see that we really need something that is more than outpatient care but is not prison....
Seattle, has crisis levels of homeless people, many that have mental illnesses. I can assure you that, even if you think it would be cruel to contain and treat them against their will, it is certainly not compassionate to allow these people to live on the streets with no shelter and no consistent source of food or medical and mental health care.
While it is 100% true that most mentally ill people are not violent, we've made little to no distinction and no provisions for the people who are (those who've demonstrated aggressive and paranoid behaviors in the past) and ignore that mentally ill people actually are more likely to self harm. We've unfortunately turned this into a police problem and they 1) are not mental health professionals 2) are generally called in to deal with the aftermath of events, not prevent them.
When people say you just don't want to see them.. well... tell me would you not feel endangered when a young man is stalking around screaming (to no one) that "You are hurting me"... When it's clear that he's experiencing something that you cannot see and you, by simply being in the area may be deemed the source of that pain? Encountering people like this is not uncommon here these days. They are the people that need more help than we now give them - help that we've eliminated in the name of compassion.
8
Phillipe Pinel (1745-1826), a French physician, came up with the radical idea that treating mentally ill patients with compassion, respect, and kindness worked better than throwing them in jail, feeding them bread and water, and beating them if they complained.
There was a long history of incarcerating the mentally ill in the US until the groundbreaking work of Dorothea Dix that established private and ultimately public asylums after the Civil War. Of course the discovery of neuroleptic medication in the 50s changed everything and led to the deinstitutionalization of thousand of patients without an adequate mental health infrastructure in the community.
And like no other country in the industrialized world in the 21st Century, community mental health and affordable healthcare services in general in the US are on life-support: look at the infant mortality rates.
It's a convenient dodge to talk about mental health and asylums -- not guns -- after a school shooting, but when it comes time to fund community mental services there's a strange silence. And locking people up in America seems to be a panacea for many social problems when more humane and effective solutions are not even considered.
3
You won't find the solution in LA. The state legislature, years ago, in its infinite wisdom, made it illegal to make cuts to anything but education and health care. No one has ever been able to explain this act of lunacy to me. It seems to me that keeping your people healthy and well educated should be a priority, rather than an afterthought. Yet so many natives love LA. I, for one, will be more than ready to leave this state when my wife retires.
This issue is another drop in the bucket of my personal confusion as to why Republicans keep removing funding for the humane treatment of needy Americans. Republicans have never found a single social program they will publicly fund. We need better programs but they prefer bloated prisons. We know from research that support can turn a person's life around, but what Republican believes in research or facts? It's heartbreaking to see how one political party with half the American population is willing to dismantle anything that's good for struggling people and their families. But of course the wealthy need tax cuts.
2
It would be interesting to find out why these community mental health centers didn't open. Was it the federal government or the states who didn't provide the resources to support them? Who were these centers supposed to serve, low income people or everyone?
Another facet of the problem of untreated mental illness is that, according to Senator Joseph Kennedy, the federal agencies, like the Labor Department and the Centers for Medicare and Medicaid do not enforce the Mental Health Parity Act. He says that after Congress passed the Affordable Care Act, there was a tacit agreement between the insurance companies and these agencies to avoid enforcing the parity law because the insurance companies had made concessions to get the ACA passed:
https://www.npr.org/2015/07/29/427464632/health-insurers-flout-federal-p...
1
There are half-a-dozen Law and Order episodes from twenty years ago that point to what's wrong. A schizophrenic needs to take meds. They give the pills to him/her in the hospital. But as soon as the person leaves, they don't like the medication, stop taking it, start hallucinating, and become a problem to themselves and others. SOME form of compulsory oversight, if not institutionalization, is the only answer; drugs are necessary but not sufficient. The alternative is often what befell to Senator Creigh Deeds' family.
2
As the "Hearing Voices movement" has shown, 17% of the world's population has hallucinations. Only a tiny minority of these people actually really suffer, though.
Oliver Sacks too already discussed this in his books: hallucinations are just visual or auditive phenomena, which can be scaring, neutral, or pleasant.
Only the terrifying ones are a real problem, preventing people from leading a normal life, causing panic attacks etc. And that's when drugs indeed may become necessary, until a way has been found to strongly reduce stress and negative thinking/emotions (which appears to then lower the number of negative hallucinations too, replacing them with more neutral ones, which don't cause any problem once it's acknowledged that they don't mean that you're "crazy" at all, but are probably merely brain effects, which aren't harmful or caused by a serious problem with "who you are" at all).
Our current psychiatry, however, tends to see hallucinations as a "disease" (they're NOT, just like being colorblind isn't really a disease), and once drugs such as haldol lower their frequence and/or intensity, doctors conclude that you must "be schizophrenic". That kind of (utterly unscientific) "diagnose" is often enough to destroy people's self-image and their hope for a better/normal future.
Today's pharma industry and many psychiatrists continue to PRODUCE their own patients - rather than treating them as normal people, needing love, connection and compassion just like anybody else.
1
No. Oriflamme, the alternative to “noncompliance” is usually a “lost cause” who rebuilds their life. I’m living proof of that.
How is it possible that in the U.S. a person might be forcibly hospitalized for being "a significant danger" to himself?
As far as I can determine, suicide is not longer considered a crime. Now, it's high time for the mental health experts to let go of religion's hold on their notions of sanity and let us die if we decide that's the right thing to do.
You've got enough to work with -- and you're doing not a good job.
2
Because of its reputation for tolerance and its good weather, San Francisco has a huge number of homeless people with severe mental health and/or addiction problems. It is a huge problem - it has become routine to witness extreme antisocial and illegal behavior in downtown at any hour of the day. But neither the city government nor the courts have been able to do anything. San Francisco cannot afford to provide housing and care for these people, and doing so would only attract more.
1
I understand that many patients were in asylums decades ago and we can argue about the type of treatment they received. But psychiatry is a relatively new field of medicine which has grown tremendously over the last 50 years. This has enabled providers to follow established practice parameters in the treatment of individuals with mental illness. Not only is the current community care setup broken, it is also starved of cash. States continue to cut their mental health budget and appropriate services cannot be rendered. For the county I reside in, I payed more tax for the maintenance of the community zoo than the mental health center! Besides these factors we must understand that patients with certain mental illness' such as schizophrenia and bipolar disorder struggle to care for themselves and require 24/7 care. There is no way a community care center can provide this. Long term care then becomes necessary. We need to stop finding ways to shift the blame and start providing the resources the most helpless members of our society need.
5
A nettlesome social problem that, given the statics of any given population, that will always be with us to one degree or another.
Where's the humanity in letting them wander the streets alone or be hidden by families from the public because they simply don't know what to do and have no means to get help.
It would be worth our time to study how Japan, Germany, France, and Italy, for example, deal with similar mental health issues and look at their programs and success rates.
But the bottom line is if we can afford an F-35 program in the trillions, we certainly can put our resources to work on those among us who truly need care and shelter.
5
AliceRest - since Trump loves his despots, its more likely he would look to those countries and how they deal with their mentally ill. Russia, Philippines, now North Korea, former Soviet states, etc...
So don't wish too hard for that tactic to be used...
1
There is no perfect solution to this. It will take a great deal of effort and money to come up with anything that approaches a workable solution. I do believe that some people would be much better off in an institution and society would possibly benefit as well. Strict oversight by the courts and/or responsible agencies would be a must. There will be mistakes and issues will arise. Deinstitutionalization was a failure and so has been the so called replacement.
1
This article's first point of demanding sensible commitment standards is something I have long advocated for. I currently work with people with moderate to severe illnesses in the outpatient setting. One of my clients - a young adult male diagnosed with schizoaffective disorder - was living at home with family. We placed him on an involuntary hold. At the time he really didn't meet the strict criteria for involuntary treatment: he wasn't threatening to harm himself or others, and he was housed, clothed and able to feed himself, so he wasn't gravely disabled. However he stopped taking his meds, was drinking heavily and, as a result, decompensating. His negative symptoms were pronounced. Some clinicians would see that and decide not to have that person involuntarily admitted and, by the law, they would be right. But this person was making poor choices and, as a result, their illness was taking over in a deleterious way. We had him admitted. He was at the hospital for several weeks, discharged to a step down facility and eventually got into a local board and care facility where he is free to leave during the day but also gets the medical and social support he needs. I meet with him weekly to work on different things like healthy coping skills and socializing. He's doing so much better, but it took the initial (and controversial) steps of temporality taking his freedom away. People have the right to make poor decisions but when those decisions impact their health should we allow.
5
Chris Christe is eating through his lap-band. His “bad choice” is hurting his health. Are we going to cage him? John McCain flew in an airplane recently to vote down an ObamaCare repeal — even though the flight might have exploded his cancerous brain. Are we going to cage him? Obama smoked cigarettes. Hillary Clinton worked until she collapsed. Are we going to cage both of them? Until we do, you have NO scientific of legal leg to stand on. MAD PEOPLE WILL NOT BE EXILED FROM SOCIETY OR REDUCED TO SECOND-CLASS CITIZENSHIP!
1
Mental health parity is a complete joke. It doesn't exist at all in Medicare which is the insurance for the disabled and seniors who are mentally ill. Co-pays for mental health care are far more than those for other medical providers. The high co-pays combined with the shortage of providers mean that care is out of reach for many of those who need care. I don't know what the answer is, but I suspect we are going to have to commit resources to a far greater extent if we are going to care for the mentally ill in any humane way. Leaving care to jails is no solution at all.
2
I would ask The Times to present evidence to support its calumny that mental health professionals don't try to get potentially dangerous people into inpatient facilities because their are limited number of beds.
As a healthcare professional myself who has had patients who needed mental health care, I've never run into one of these professionals taking a powder on trying to get patients the proper care. Sadly, because of inadequate funding on the part of governments and discrimination by insurance companies, this is often not only difficult but impossible.
3
The most up to date research on Portland's homeless population revealed that 75% are experiencing mental illness and/or drug-alcohol addiction. There is wide support in the city for reopening a former jail to shelter homeless individuals. We're responding to the needs of chronically mentally ill individuals with the offer of a kind of voluntary asylum minus the treatment (however imperfect) such places offered in the past.
3
Problems with state mental hospitals were already recognized at the beginning of the 20th century as even then there were multiple newspaper exposes about poor conditions within them. The reason why we are continuing to debate the same issues is for the same reason as back then: money.
This country never has taken mental illnesses seriously and has continued to largely view them as moral failings and not "real" illnesses like physical illnesses.
The only thing that liberal Democrats and conservative Republicans always seem to agree on is the underfunding of mental illness. In New York, when the state hospitals were closed in the 1980s and the money the state made from selling off the real estate was supposed to go to funding outpatient facilities, that great liberal paragon Governor Mario Cuomo took the money and spent it on other things. And one of the first thing things his son did when he became governor was to cut funding for mental health programs.
4
The de-institutionalization of thousands of people with Developmental Disabilities in New York State following the Willowbrook Consent Decree showed how, with adequate funding, the large institutions could be closed, and the people safely returned to community living. By and large, the Developmentally Disabled were placed in group homes and sheltered workshops with adequate staffing.
In contrast, at around the same time, New York State began to de-populate its many institutions for the Mentally Ill, but, not driven by a Consent Decree, the legislature did not provide the necessary funding needed for community-based services and living arrangements. This lack of funding support haunts the system for the Mentally Ill to this day, and is why the mentally ill homeless people are left to roam the streets, victims of this underfunded and truly heartless "dumping."
3
I'm for group homes for people who have mental problems which can be ameliorated by medication. Unfortunately, many individuals will not take their medication unless supervised.And yes the criminally insane should be separated from the generally prison population and receive psychiatric support. I don't know to solve the homeless problem, but we as a society must provide care for those who are homeless because of mental and physical illness, as well as giving families basic subsistence.
3
I am a Public Defender who is assigned to a mental health specialty court and am an advocate for opening up state run psychiatric hospitals for long term care of those suffering from serious mental illness. The reality is that the mental health system currently in place is woefully inadequate in terms of capacity due to it being underfunded by both State and Federal allocations, and in many jurisdictions, it's run by giant for-profit corporations that siphon off a large percentage of the funding before it allocates a dime to the agencies (mostly nonprofits) who actually provide the services. Similar to the for-profit prison model, corporations have figured out how to profit from our country's institutional failures.
County/city jails have become the de-facto treatment centers for those with SMI, but in a week or two, after being stabilized with meds, meals, and a relatively safe place to sleep, they are released; in all too many cases, with nothing more than a phone number.
By far, the most critical issue for my clients is stable housing. Without it, taking and refilling medications and maintaining out-patient treatment is nearly impossible. Well run State psychiatric hospitals would be 100 times better than the current system.
6
The problem with community based homes is that no one wants to live next to one.
7
Prison IS the new insane asylum. I started as a Los Angeles public defender in 1990. The number of severely mentally ill people on my caseload has increased significantly. At any one point of time, 15-25% of my felony clients are incompetent for court. The mentally ill were kicked out of the hospitals and told to survive on their own. They live on the margin, and one psychotic episode puts them on the street where trying to keep and maintain a medication schedule is impossible. A new solution has to be found. It is not fair to the mentally ill and it's not fair to the victims of their crimes.
4
Anybody who's "been through the system" knows very well that asylums never went away, they just switched buildings. Now "those people" are in county jails and state prisons. But I guess it doesn't really matter, you never see those people anyway.
1
Nice outline, Editorial Board, really nice outline. But it lacks any specificity that might lead to the actual implementation of schema that might actually solve the problem...
And do I detect a touch of moonwalking in your current editorial and a left-handed admission that the full-throated support of the elimination of mental health facilities throughtout he period of 2000 through the present has been a monumental failure?
Anyone with a touch of reason back then foresaw the problems with the elimination of facilities dedicated to housing the mentally ill without having a functioning system in place BEFORE facilities were closed down. Anyone with a touch of reason back then understood that the issue of mental illness and the potential consequences of loosing the mentally ill into a poorly or unsupervised environment could have serious consequences to the safety of the community...
It is to late to snap back to the way things were, nor would it be particularly productive given the needs to reintroduce the systems, programs, and institutions that were thrown out with the bathwater over the past 18 years.
I would hope, however, that as the esteemed Editorial Board pontificates in the future on issues for which there are significant consequences, they consider carefully the impact that the suggestions might have on the practical problems of implementing, and on the significant consequences of program failure might have on the society into which they are introduced.
2
All I can say is that had the democrats thought that this would be a good idea to garner votes the article would be much different. Never-Trumpers are child like
I live in the Czech republic and have a Slovak cousin who is schizophrenic. He lives in a home, but he comes to our family reunion. He also visits his parents on the weekends. When I see him, he is healthy and well kept, and talks openly about what his life is like. I feel sorry for him, and I don't want to present the situation as being ideal. However, I know his parents are glad that the government pays for this service and I believe that he is better off in the home than if he were to be forced to fend for himself.
There truly is a middle ground between "One Flew over the Cookoos nest" and keeping all the crazy people in America under a bridge in Oakland, CA. You don't even have to keep most mentally ill people locked up. Many mental patients in the Czech Republic, who are in homes, are aloud to leave during the day and even keep jobs! The police are called if they don't come back to the home at night, but that is for the good of the patient. I hope I'm not deceiving myself, but I really cannot see that as being tyranny.
4
You can see a photo-gallery of a permanent home for Schizophrenics in the Czech Republic here: http://www.domovjaroska.cz/fotogalerie/
1
Where to begin? To even begin to address this issue would require 15,000 characters, 10 times the allotted 1500.
In our local newspaper, the Sarasota Herald Tribune (formally owned by the NY Times), Carrie Seidman, via a fellowship did a year long series of articles, facing Mental Illness, which attempted to offer something of an overview of actual people's lives which had been touched by Mental Illness.
http://faceingmentalillness.heraldtribune.com/
definitely worth a look/see for those seriously interested in this subject.
The treatment system is a mess, has been since de-institutionalism began. Perhaps the movement was well intentioned, although I have my doubts, I still believe it was really a cost cutting movement. Since then funding hs steadily gone down in real $$ so that less and less is available. Here in Florida, Governor Scott's answer to the huge opiode crisis is to cut treatment dollars by almost 10%.
I worked in Child Protection for 15 years and one young man remains a vivid memory. Every case worker involved understood that he would never be safe in other than an institutional setting, but every time he blew out of a high dollar placement, the standard mechanism was to temporarily place him with the mother while another placement was sought. It was pretty much understood that what was needed would never be available as a juvenile and probably not as an adult, post age 18.
The mental health system needs more than more patchwork, a major overhaul.
4
The political will to establish and maintain a broad network of "mental institutions" across the United States is totally lacking, in this era where the only agenda item the President and Congress will fight for is to cut taxes, mainly for the wealthy. Otherwise, they lie and deny. I write as the son of a mother institutionalized in a mental state facility for more than 20 years, where she was misdiagnosed as paranoid schizophrenic, and more likely suffered from bipolar disorder. She suffered more than 75 electric and insulin shock treatments, which contributed to her disorders and undermined her recovery, though more modern treatments of lithium and group therapy would have produced a nearly normal life for her -- according to a clinical psychologist who worked for years at National Institutes of Mental Health. Medicine for mental illness has come a long way, but a real solution needs funding, training, and dedication to solving this widespread problem. We need to elect people who care.
1
The crazy talk about asylums is no crazier than most other things that come out of Mr. Trump's mouth.
What is crazy is that there is opposition to limiting the availability of guns. What is crazy is that Mr. Trump or the GOP have spoken out and directly said that gun availability in this country needs to be restricted.
Other craziness about Mr. Trump's administration, an EPA administrator that is taking apart the EPA and does not believe in climate change, a person who is currently POTUS that gets news from FOX rather than reading intelligence reports, a President that refuses to testify before the FBI, a President that refuses to release his tax returns, a President that lies all the time and no one confronts him directly about his lies. So this talk is sadly no crazier than anything else from Mr. Trump's mouth.
It’s obvious when editorials are written by people comfortably esconsed in suburbs accessible only by car.
Live in an area where cars are not needed and you will support asylums, even as simply more humane storage than living on the street.
2
When Reagan a GOP nightmare was President he and his group managed to close all the mental health hospitals. He needed the money for his Star Wars missile system. This 2018 GOP hate mental health care in any of their fake health care plans and were going to charge us 5 percent more for coverage .President Obama thoughtfully included it in his Affordable health care. The GOP canceled that when they took over. We need to stop hiring the GOP.
1
Our streets and prisons are the insane asylums. Good luck letting kids play outside in San Francisco.
3
An ounce of prevention is worth a pound of cure. (B Franklin)
There are known causes of mental illness:
1. traumatic brain injury.
2. Early childhood neglect and trauma
3. Severe trauma for older children and adults.
My prescription for prevention:
1. prevent physical injury to the brain: really pay attention to
problems of danger to the brain: why should anyone court
brain injury by skiing off the groomed trail? why should
anyone participate in a sport that involves head injury?
Perhaps health insurance companies should NOT pay for
medical care for head injury from a dangerous sport.
2. Assume that anyone who has been in a war zone, or a terrible
accident is going to have PTSD and treat them BEFORE
they ruin their family relationships and lose their jobs.
3. Absolutely provide REAL family planning and birth control to
every woman in the U.S. who wants it. All births should be
wanted, planned babies. Unwanted babies can cause
family chaos and dissolution with much much higher risk of
abuse and neglect of the child.
PREVENT PREVENT PREVENT.
ALL THESE PREVENTIONS WOULD SAVE LOTS OF TAX MONEY!!!
1
If mentally ill people were sent to institutions rather then local hospitals it would free up beds and care for other patients in need. Also, the staffs at the ERs would not be constantly burdened with out of control, suicidal or dangerous individuals.
3
We still have asylums for the mentally ill. They are called prisons.
2
Fritz Perls once said (not exact quote) "there are three kinds of people, those who are OK, those who are not OK, and those who take care of those who are not OK on behalf of those who are OK." One can be really not OK, societally-defined not OK, and both. Asylums are just one interdependent element in the ecosystem that takes care of the "not OK." The first goal of those OK is to contain the not OK. The second goal is to try to help the not OK become more OK. How much we emphasize containing, helping, and blending getting the not OK appropriately contained and helped, is a measure of our humanity. So far, getting the not OK contained far outweighs helping them.
Without a well thought out budget and a willingness to commit resources , there is no meaningful discourse. Good mental health care would be expensive. Let us start with a realistic budget and then have a discussion about what we would be willing to give up to pay for it.
1
In the old asylums, did people sleep on cold pavement in clothing soaked with their urine and feces and vomit? Did they wander delirious into busy city streets and get run over by cars and trains?
Did they get crushed to death in garbage trucks because they fell asleep on a pile of trash in a dumpster? Did they meander on an endless trek, unable to sit down or lie down because a policeman would tell them to move on or fine them for loitering if they did not? Were all their belongings, the tent and sleeping bag they had received only weeks earlier from a church, along with personal photos and mementoes all taken away from them in a nighttime raid and crushed to nothing in the back of a garbage truck?
Did they stay awake all night to avoid getting mugged or raped? Were they raped repeatedly and never treated for that trauma? Did they get stabbed and bleed to death in an alley? Were they trafficked as sex slaves? Forced to become a drug mule?
Were they handcuffed and thrown into a police car? Dumped in a prison cell alongside several dozen hard-core criminals? Beaten for not complying with orders and beaten by fellow inmates for simply existing? Placed naked under 24 hour video surveillance? Thrown back onto the streets after a horrific stay in prison?
The horror of life for the mentally ill today is why there is talk about bringing back an improved version of the old asylums. Our streets and prisons are even worse.
20
No they didn't wander the streets but they were treated less like less than human beings "locked up". From an old nurse who remembers...
In the past, people were unjustly committed to mental institutions and many in the institutions were not treated well. Mental institutions were not a place to get well. Most patients were over sedated so that they would not be a bother. If mental institutions are reopened, they need to be cleaned up and patients treated so they can be well and not abused. Some patients were kept in the institutions because they had no where to go and were left to die in the institution.
3
Some people are never going to “get well”. That’s the point.
2
I am a clinician, and we need more long term, inpatient options for the severely mentally ill, as well as an effective prevention models, as all mental illnesses, including addictions, are diseases of young people.
Right now we only have short term acute care, and one must be homicidal /suicidal, or the like to be admitted.
10
Thirty years ago, I was working in community mental health care, on the receiving end of those being let go from the state hospitals which were being closed. My colleagues were joking that in 30 years, someone would be saying, "Hey, wouldn't it be a good idea to have some hospitals for people with mental illness?"
Sadly, as a Frontline Documentary proclaimed, prisons are the new asylums.
13
I second that and more.
1
I do not have the answer for our present mental health crisis, but I do know that large institutions are not the solution. As a young student nurse, my psychiatric training was at SF General Hospital. It was a traumatic sight for a young naive woman. The degree of mental illness was staggering, so many individuals crowded into a relatively small site with exhausted nurses and physicians.
We have made little progress in treating our mentally ill. It has been 2 steps forward, yet one step backwards, which in a sense is an improvement. At this point, I feel it is necessary for readers to know that although it affects a different age group, the rise in dementia - whether it be stroke related, PD, Alzheimer's, etc. - is becoming pervasive in our society. Many of these seniors are often destined to live their final years in for-profit based so-called Memory Care units where they pay an exorbitant price for often negligent care. Be aware that most, at least here in California, are all about making money for the corporation involved with care givers who are often uneducated, inept, and unconscionably underpaid. For a "wealthy" nation our lack of compassion and moral compass toward our most vulnerable is, I dare say, shameful.
3
How can the Editorial Board suggest its three proposals for reform are not very controversial? Each would require significant sums of money. That's always controversial.
3
Common sense solutions are just that: common sense. That's the very opposite of controversial.
The money is merely a matter of political and moral decision.
That means having the courage to say no to your wealthiest campaign donors when they ask you to vote for one more gigantic and unpaid for tax cutting bill, as a politician.
And it means having the courage to inform yourself and then vote for politicians who are willing to really care about America's greatness rather than just talk about it and then once elected merely care about their own careers and the wealth of their wealthiest donors, as an ordinary citizen.
In a democracy, we only have the government - and greatness as a society - that we deserve ...
(and then we're not even talking about the fact yet that, just like with other types of healthcare, nothing indicates that finally installing a decent mental healthcare system in this country would end up costing us MORE rather than less money than the current situation - knowing that today US businesses loose $30 billion a year only because of low productivity of their employees, provoked by stress levels that are too high combined with the absence of serious, effective stress management tools).
1
Sadly, common sense is not the opposite of controversial. Some of the most common sense and moderate solutions to problems our country faces are the most controversial.
Yes, our problems would be solved if we had courageous, moral, sensible politicians who put the public interest first; and a courageous, sensible, informed electorate. Saying we should have these things does not make it so.
To understand why we do not, follow the money.
Having worked as summer staff at Dayton State Hospital before I went to college, I witnessed firsthand the state of the "asylum" in the mid50s.
Every working day, I was assigned to a new ward because I was replacement for permanent staff on vacation. So, I observered the breadth of mental illness, all with women. These suffering people could not function in outside settings where they had to care for their physical bodies and carry on a life. A few were discharged, but very few. All these years, I have shuddered to imagine these people out in the world in their mental conditions, many homeless, just abandoned. Such a cruel, money hungry society.
12
This editorial is well-intentioned, but those of us who have a family member with intractable, severe mental illness, know that a system of asylums would be far better than what exists now, and that your ideal system will never happen. We need MORE commitment of people who are ill, not less. The ideas that you are talking about were brought up years ago and never put into effect because they require more money than a republican administration was willing to give.
4
Let’s look at the related area of special education in public schools, as a fraction of these kids are headed toward adulthood with serious emotional, developmental issues that put them directly into the disorganized and unfunded morass we have now. In my state, room and board per qualified student is about a quarter-million dollars a year, not including instruction, and the average cost per special needs student is about twice what is spent on the remaining 80-90% of students. These costs are not supported federally except in arbitrary small part, states try to reflect them back to school districts, and only a mess ensues. But why do we have this at the same time we’ve literally kicked adults to the curb?
The answer is ugly. Kids have a voting lobby, called parents, and it’s easy to connect public education with special needs. Adults are on their own, totally out of our society. With the lack of universal healthcare, enormous pressure by the pharma industry to substitute chemicals for any other kind of treatment or service, and ineffectiveness of ‘hire the handicapped’ legislation to bring people into the workforce, we have arrived at a sickness that seems to have no cure. How about we start thinking about a real, planned, federal nanny state? As good a word as asylum used to be.
4
The continuing gun violence at our schools is an on-going tragedy for America, and is a unique facet of our American culture. No other country in the world faces this senseless carnage.
But, it is a horrible disconnect to fantasize about the return of the "asylum" as a deterrant to these ugly shootings. Rage, anger, the need for revenge, etc., are all part of the human condition for all of us. To hold the foolish belief that we can eradicate these negative emotions through building locked wards and high walls throughout our country is simply "Trumpian".
Prevention, early detection, far greater community mental health support for our communities (and delivery of those services in new, creative ways to the alienated-adolescent, and others), can truly alter the endless carnage we all experience and greatly reduce this repeated horror show.
We need to pull together a national commission promoting new ways to deliver postive, healthy mental health intervention - before anger turns to bullets.
1
The cost of lost workdays is 193 BILLION, rather than 193 MILLION, and that was back in 2008.
The total cost of mental health in the U.S. is now estimated at 444 billion/year
https://www.usatoday.com/story/news/nation/2014/05/12/mental-health-syst...
1
Ronald Reagan. A truly nasty man hiding behind a benevolent smile, often under a cowboy hat. How American could you get?
Well the country can thank him for wrecking the California health care system in the '60s by defunding it to the point that patients were wandering around freeways during rush hour. Closing the state asylums and funding carefully set up local out patient care had been working until Ronnie gutted it. I was a graduate student in Oregon at the time and remember him on tv blaming it on the 'liberal'psychiatrists who he implied were plotting against him.
Governor then, he went on to abetting greater atrocities in Central and South America. A truly great American.
7
Most humans would agree that autonomy is important to well-being. To make our own decisions (even when they are bad ones) support the freedom our nation purposes. However, when that autonomy forces maleficence and injustice on others, it is often sequestered by our existing laws.
Many seriously mentally ill people (harmless or not) cannot make autonomous decisions about daily life. They often need many different forms of support. The 1980's idea of suddenly freeing them from asylums might have gone well if we had carefully planned a community based living opportunity. Instead, we released people into the streets (literally) then were astonished that they became homeless, addicted, and sometimes dangerous (often to themselves, occasionally to others).
My grandmother was a psychiatric nurse in London Ontario in a era when we locked up everyone in either a psychiatric hospital or jail who had chronic or acute mental illness. I'm sure rapes still occurred as the media doesn't support daily acts of sexual violence against women. But, I wonder if people,in general, felt safe, able to walk in the park, enjoy their neighborhood, send children to school and know they would come home alive.
In instutionalizing seriously mentally ill people, are we causing more harm or more beniefience?
1
A few more issues that contribute to the current mess:
- there is a shortage of Psychiatrists, and the gap is widening as older docs retire. Not enough are being trained yearly, and there are not enough residency slots for them (Congress/Medicare need to create and fund more Psychiatry residency training positions).
- There need to be better incentives to recruit new Psychiatrists, like better salaries and student loan forgiveness
- The bureaucratic burdens which impede meaningful patient care need to be reduced, including:
1. Tedious and irrelevant "E&M documentation" requirements [including "documenting 3 vital signs for Psychiatry patients]
2. Time consuming and expensive "quality measure" tracking/submission requirements mandated by the MACRA law. And most of the measures Psychiatrists must track/submit are not mental health related.
3. Expensive EMR/EHR (electronic Medical Records or Electronic Health Record) compliance burdens from the HITECH law, that mandate doctors must use expensive EMR's [which are NOT interoperable in the way the gov't intended them to be, so instead they are just a VERY expensive burden to doctors, and a huge boon to the EMR industry]
In addition to what the article has detailed (lack of beds, lack of parity in payment to mental health docs, etc), these are among some of the other very real logistical/financial/bureaucratic problems faced by practicing Psychiatrists in trying to help their patients with mental health needs.
2
Oh come on, how 'tedious' is it to attain blood pressure, respirations and heart rate.....especially when those vitals can be elevated, when a patient is in a state of high anxiety (etc)?
Also only 2 vitals are necessary....you will only be able to charge for a lower level encounter, but you aren't 'required' to do 3.
Out of everything I listed, that's your retort?
What do 2 or 3, vital signs have to do with providing mental health services in an outpatient office (which can't afford to hire medical techs/nurses because of slim margins). And billing with 2 vitals, and lower level encounter, only leads to even slimmer margins (and then going out of business).
Psychiatry previously had its own codes, without many of the arbitrary requirements, like vitals, Review of Systems, etc - that E&M notes require. Psych notes were removed by AMA/CMS, and Psychiatrists were forced to use "medical" E&M service/billing codes.
How does it help Psychiatrists provide mental health more effectively or efficiently - a problem this article identifies? (And if mental health providers/Psychiatrists don't meticulously include these arbitrary data [irrelevant to the situation] - the note and service are then "out of compliance", causing the note/service to be deemed as fraudulent billing, which can lead to severe penalties and possible loss of medical license).
We need much better alignment of "documentation requirements" for mental health services, with much less arbitrary hurdles.
On that note - AMA makes 2x's the income on their proprietary CPT service/billing codes, than on physician membership dues. In other words, AMA's primary business by 2-to-1 factor is actually "billing codes", not representing physicians. To the tune of $72,000,000 income from codes in 2010.
Where are our priorities?
1
About 20 years ago, my daughter was called by the neighbor of a friend of ours to come and help him. This friend had a history of serious mental illness and was an alcoholic, and the neighbor said he was "going nuts." We got a male friend to help us with him since he was being quite combative. We got him into my car and took him to the local emergency room on Long Island, where we lived. They wouldn't take him in the mental ward because he was drunk, and the detox ward wouldn't take him because he was mentally ill. We put him back in the car and took him home, where we stayed with him until he was as stabilized as he ever got. Incidentally, our friend was the heir to a British china company and was financially comfortable, and still couldn't get any consistent mental health care. Had he been a poor man he would have been on the streets or in jail.
6
De-institutionalization (without any actual plan for how to help those who need it) was a disaster. The result? A lot of homeless people are on the streets because of severe mental illness. Many have ended up in prison (which does cost a lot of taxpayer money).
Something really needs to be done. People need to wake up to this problem. But unfortunately, unless you know someone with severe mental illness, you probably don’t understand.
If you happen to develop a severe mental illness (and don’t have a great family structure/support and lots of money), chances are will end up on the street or in prison. That is the reality.
2
The flaw to this article is exemplified by the words "need and deserve". If you want these centers funded, you need to focus on the financial argument. The mentally ill COST police $$ (insert the correct number) per year nationwide. They COST the court system $$ per year, the insurance industry $$ per year for the damage they inflict, emergency rooms $$ per year, and so on. When you add up the expense attributed to the lack of care, treatment becomes the lesser expense and therefore appealing to the heartless vermin that is congress and Trump.
In Phoenix in the 90's, the right wing, short sighted legislature decided to stop giving free meds to the mentally ill homeless people. Free meds offended the conservative right wing but when criminal incidents skyrockets and filled up the courts and jails, the right wing relented. Once the mentally ill arrived in jail they were given free drugs anyway so why not provide them in advance and avoid the expense.
In my experience dealing with legislators who have no compassion, the only thing that works is an Excel spreadsheet.
2
THIS. This is something liberal media fails at over and over again. Take illegal immigration, for instance; they talk about it being the ethically right thing to do, to let people in who can't go home because of violence, poverty etc. This is true, of course, but what they don't do is lay out the NUMBERS supporting the fact that even those who don't care about the wellbeing of others should support paths to citizenship for undocumented immigrants, because they contribute $$$ per year in taxes, $$$ per year in this or that field (i.e., agriculture), etc. We have to stop waiting for people to develop compassion and start hitting them with NUMBERS to combat their knee-jerk "it's too expensive!" reactions.
People with mental and physical disabilities of various degrees require enormous amounts of resources financial and a disproportional ratio of patient to manpower with very little return for society as a whole. People who will have to deal with it often neglect their own healthy children and to their own detriment.
If we can avoid many of these problems at the fetal level through genetic testing we should certainly encourage abortions or genetic manipulation. Keep religion out of it and do the right thing.
Schizophrenia and other major mental illnesses cannot be detected with a fetal test. These illnesses often do not manifest until young adulthood or later.
The worst and most destructive outcomes for mental illness often derive from reflexively treating those suffering from such afflictions with total segregation and confinement. Group homes, proper clinical supervision and social worker support provides an solution with less economic and human cost by far than mass institutionalization ever provided.
One can only hope that society does not collapse into the fetal position of catatonia that embraces isolating and denying the existence of those with chronic mental issues.
3
We may not "want" a return to the mass institutions made notorious in popular fiction like "The Snake Pit," "Cuckoo's Nest," etc., but do we want mentally ill people roaming the streets, camping out on buses and subway terminals, unable to help themselves? (Talking loudly in public to apparently nobody is no longer a stigma in a cell phone age.) Because that's what we've had since the public asylums closed.
5
Thank you for publishing this perspective.
1
This editorial urges our governmental institutions to take actions that they have failed to take for decades. Talk about a panacea.
It's time to disabuse ourselves of the notion that it is wrong to institutionalize a person who who freezes in the winter, hasn't bathed in months, eats out of garbage cans, and defecates in the streets. It is not ideal, but for such people at least an institution provides warmth, food, and some semblance of cleanliness. For God's sake do it.
4
Anyone riding the New York City subways can tell you that the subway system has become a de facto institution for countless mentally impaired homeless. This is the ad hoc ‘solution’.
4
So instead, we use jails to house the mentally at great cost and place an added burden in the police to address the problem of the homeless who are not able to care for themselves, and who will not that their medications.
No, asylums by and large will not address school shooters who are often young, with problems not yet diagnosed. Nor would they find the majority of mass shooters.
But asylums reconfigured as 21st century institutions, where the residents receive their meds and counseling, keep their pets, and are treated to something better than a new version of Bedlam is so clearly need, NYT editors.
If you do not believe, get out there on the streets with homeless people you are ignoring.
12
The near and soon-to-be homeless are also out there on the streets.
One has to look a little bit harder to find them, but that is not in the best interests of the social workers and the organizational masters..both management and union...who see "doing the job" is secondary to hiring and retaining the disinterested.
1
Visit any neighborhood in LA (this applies to virtually any American city) and you won't have to wait long before you see someone who is completely insane wandering around, talking to himself, filthy, disheveled, and raving. Many of these people are so resistent to accepting help that the only alternative is to compel them.
When they started setting the city on fire this winter, the mayor explained that there were so many homeless camps that he couldn't possibly police them all.
Of course, if you as a citizen report such a camp to the city authorities, here's what will happen: ABSOLUTELY NOTHING!
"Community care" assumes that these folks are capable of living independently within society, something which is demonstably untrue.
2
Trump is not always wrong, though he is most of the time. Even a stopped clock is right twice a day. And Trump's clock has slowed immeasurably. Nevertheless, while there is no evidence that any mass murderer would have benefited from institutionalization, society might have avoided a catastrophe if they were. What Trump fails to comprehend is that most mass killers do not present as raving maniacs, but more like people with adjustment issues that surely would not warrant a lifetime commitment to a mental institution. So who should be institutionalized?
If you look at some of the people who live on the streets of any big city, you would not need a Psychiatrist to determine that they are in desperate need of 24 hour a day care for as long as it takes. And a mental institution is the only place they are going to get it. There is no benefit to anyone in letting them live in squalor on the street until they die.
2
Let's back up. I think the debate needs to be framed this way: Can every human take care of themselves?
The evidence around the country in cities like SF and San Diego is NO. I have heard the percentages of the homeless who can not take care of themselves at about 35% to 60%
We walk to work skirting human feces and drug addicts shooting up. We are terrified by the screaming schizophrenic's who threaten us as we walk along. We hire private security to get encampments off of our property.
We take our friends to union square and the crazy woman goes to the bathroom in front of us. My neighbor is scared of the crazy veteran who Stands in front of her house and directs airplanes to drop napalm.
My neighbors house was taken over by a homeless person when he forgot to lock his door. It took 40 city workers (swat team, police, fire, ambulances) 11 hours to get him out of the house because they were afraid to hurt him. Then he came back again 3 days later.
I am all for individual rights but not at the expense of public safety and the health of the overall society.
We need to create a humane way to get these people into the care of the federal, state or local government.
I am all about individual rights for all but it is not working. SF spends a hard dollars of 300 million a year and 20% of the DPW and police and fire servicing the less fortunate homeless and many should be in a public facility and not on their own.
3
We don't need asylums. We have the subways and crowded streets to keep the clients interacting with society.
1
One more reason why I see Trump as a crackpot who should be impeached. He has no clue about the complexity of the issues related to the mentally ill, nor does he care. He just has an uneducated knee-jerk reaction. He is an embarrassment to the country.
2
Sorry, Angel, I suspect, too, that you are a part of a crack-pot element in our society that thinks that throwing money at a problem will solve all of the ills of society and will wash away your sin of being a participant thereof.
The whole de-institutionalizing of the mentally ill was one of those well-meaning liberal concepts that ended up causing more suffering than healing
One would have thought, even then, that there was a percentage of the institutionalized that might do well in a more open society, and a percentage that would be doomed to fail. And then there was a percentage that might do well with a hybrid scheme of some meaningful freedoms with sufficient structure as to assure that that group would continue to be monitored as to their compliance with appropriate medical treatment.
However, in the zeal for a one-size-fits all solutions...and the usual envisioning of a budgetary windfall that could be spent on others than those whose votes could be bought...the great and the good that we call our elected officials took the easy way out and voted their interests instead of those of the people whom they represent.
4
No, you do NOT want to make it easier to lock people up and drug them against their will. It could happen to you, you know.
1
Nobody seems to understand that it's the MUSIC. Violence, misogny, racism - they're all there. I was listening just last night to a group called "Massive Attack". What's that all about? What would a 12 year-old boy make of that? Go out and shoot up a school and kill innocents or buy more guns or something? Hey, it's a free country. I can do anything I please. Oh, come on. Grow up and be sure to keep your eyes open to see things the way they really are and not measure them by how many "stars" they get on the 'net.
2
You editors are crazy. There are people that need institutionalization and inpatient care; How much more obvious can it be? How many shooting by people who are known to be mentally ill have to happen?
These places don't have to be redo's of one flew over the cookoo. They can be decent places to get better or live if necessary; with therapy and meds and safety. With sufficient and optimized resources to deal with the expanding population of mentally ill citizens and children.
How does handing a bottle of pills to a psychotic person and asking them to take them make sense?
10
Under a Trumplican suppressive Administration, large "mental" institutions would undoubtedly be used to house political dissidents using the cover of "mental illness". This would not be different from any swamp-level third-world autocratic dictatorship or a Russian Gulag or a Maoist "re=education" or the killing fields of Cambodia.
All this is possible in a deviant, politically corrupt dictatorship.
The hallmark of a sociopath is to separation prey from outside influence by denigrating allies and colleagues via propaganda to the point of rejection, then gaining political, "legal" and financial control of resources and finally assuming "absolute power".
If this sounds familiar, it is. Just look at the headlines and back stories for the past 18 months.
AMERICANS CANNOT REMAIN IN A STATE OF DENIAL any longer. If our Democracy (with a Capital "D") is to survive for all Americans, action at the poles in the primaries must be decisive and overwhelming. Trump is a plague upon this nation and the cure is replacement with a human.
2
So are they going to legalize ECT (shock) against permission? Maybe lobotomies, too? How about insulin therapy? Maybe Trump could just sign an executive order to do human brain research at these asylum institutions?
Ah, old Germany, your old ships are sailing closer to the United States.
3
When mental hospitals were closed in the 1980s the homless population began to increase by a great deal.
7
As a retired mental professional who served individuals with persistent mental illness such as schizophrenia, you have written a balanced editorial. Sadly, we have a president who lacks balance, let alone intellectual curiosity.
3
A system of quality small group homes like the ones federally mandated for those with developmental disabilities is needed for people who are disabled with severe mental illness.
Capitalism and Healthcare for the mentally ill don’t mix well.
1
How about not use the word "crazy." It's like calling someone with cancer "stupid."
1
Hi, I work in mental health for more than two decades.. My state had an "asylum" in the 60's. Thanks to the black and white thinking of people like the editorial board, we have no place for longer term care of chronic schizophrenics, traumatic brain injuries, and other severe mental health issues. These people are poorly cared for in assisted living, personal career boarding homes, and nursing homes. This un-researched "one off" by the editorial board may reflect their ideal, but it leaves no way to appeal for much needed services for a small segment of he mentally ill. Shame on you for shooting your mouth off, without including the voices of the ground troops that must make approximate decisions. Show us the numbers if you are going to prescribe a 3 step process for something you know nothing about.
7
Family used to be an inclusive nurturing maternal unit. In this context all members were cared for. The young, the elderly and the mentally troubled all took care of each other. Now family if it exists at all is a successful business enterprise with family members the chattel property of a successful male and or female professional. Home is a succession of job related dwellings often bought and sold as real estate for financial gain. Children and mates are often considered trophies for the money earner, otherwise discarded as bad investments. These discarded former family members are your homeless, your prostitutes, street criminals, drug users.
Give families and their names back to women so we can return to the female model. Just like in Nature.
2
The whole US is an asylum run by its most aggressive inmates without regard to the effects of public policy on public mental health.
1
Mentally ill people who are a danger to others and those who can’t take care of themselves and die on the street need help that they are not receiving without supervised care. Bring back mental hospitals, good ones, that treat patients with respect and whose aim is to get patients to the point where they can be released, if that is in the best interest of the patient and the community.
8
It’s offensive that the Times chose, for an opinion piece attempting to thoughtfully consider the needs of people living with mental illness, a title containing the word ‘crazy’. It reveals ignorance and a cavalier insensitivity to the struggles faced by those with mental illness to be understood and accepted.
1
Living in Berkeley, dealing with masses of the mentally impaired daily, I believe that institutions would work far better than dumping them here, for them and for the rest of us.
2
I would not think we would want to bring back mental institutions. A lot of progressive and hysterical people could end up in them.
3
This is Trump(don't)care in a nutshell:
Let the sick and poor suffer and die out, just so long as the wealthy elite never have to interact or even see them. Eventually, the unfortunates will die out -- problem solved!
Trump's no less brutal than Duterte who also allowed a highly spun end to justify his cruel means to "solve" Philippines drug crime by just killing everyone who might be involved.
For short-term monetary gain -- mostly going to the abusers at the top -- We the People will continue to lose bigly with this so-called man abusing the power of his fraudulently acquired office.
1
Homeless? Mentally ill? That's why we have police with lots of guns. America is Great!
GOV RAYGUN of Calif closed all the or most of the institutions here and as a consequence they walked the streets , slept in the local library, died of exposure in the winter cold and were basically left to their own devices. Sure, there were so half-way houses--halfway to the morgue for a lot of them. BIGLY SAD in the famous words of our CROOKED president. BTW/ many of us (and around the world) think donny would do well to have a stink in one himself.
So dignity for the homeless is defecating on the sidewalk like an animal? Dignity for the mentally ill is shuffling around in filthy clothes, talking to themselves? Dignity for autistic people is being locked up in their parents basement, while these parents are praying every day for their child’s early death because nobody would take care of him after mom and dad are gone? Dignity for the developmentally disabled is being an insufferable burden on their families? Asylums exit in every civilized country in the world. Sure, they can be abused but is the current situation in the US sustainable? Go out in San Francisco, take a look at the homeless encampments, try not to step into human waste and used syringes littering the sidewalks, and then tell me that these people would not be better off in a place where they at least have showers and hot food every day. And what about the rest of us? Don’t we need to be protected from erratic, violent or anti-social behavior?
5
People disabled with severe mental illness have similar needs to those with developmental disabilities so I suggest that we extend to them all the same federal mandates we have for the developmentally disabled.
2
To those who read these letters please notice the length and thought put into the reply’s. This is an area of genuine pain. My uncle was lobotomized in the 1940’s and put into outsourced care in the 1970’s and spent 40 years as a cash cow for opportunistic entities.
4
This and many US problems really goes to the profound injustice of a health care system profiteering through insurance companies, the pharmaceutical industry, hospital administrations being a part of this capitalist immoral rip-off and destruction of the US society. Yes started with Reagan the de-institutionalisation of the mentally ill, and yes the system was broken as it existed. But the fix will not come until the US gets out of making money through peoples´ misery.
Community mental health has democratised many mental health issues and made it impossible to commit anyone so of course abuses of commitment are avoided. But now the real mentally ill get to go into for-profit prisons. Do people who vote republican really not see the USA for the disaster it is --
3
I fear that the huge deficits provided by the GOP budget bill, which enables their rich individual and corporate sponsors to suck up that which remains of the pie from the rest of us, will be used as a pretext for worse than "lock them up" for mentally-ill people.
Romney's "47%" comment at that 2012 fundraiser, implying that the poor, the elderly, people of color, "illegal immigrants," LGBTQ people, Muslims, and anyone else on the GOP's wish-list or exclusion or elimination, are somehow "life unworthy of life," to vanish at little or no cost to the good (white) people.
Add those requiring custodial or long-term residential psychiatric care to this list of "takers," and see where the permanent trillion-dollar deficits take or put them in the current GOP orthodoxy. We've seen it before--in dead-ends featuring slogans over the gate saying "Work Makes You Free" and "To Each Their Own."
With GOP executive and legislative branches of the government, our Constitutional promises of "life, liberty, and the pursuit of happiness"--and mental health or a return to mental health for ALL Americans--mean NOTHING except "How much money can we and our friends make out of it."
3
6 percent of the 300million people are mentally ill in this country =15 million people.....20 to 25 percent of the 2 million homeless people are mentally ill ...its going to Take LOTS of Money to take care of these people/ give the Oil companies right's to drill in Alaska and build a first class place for them there with the Oil Money / everyone Wins!
Well, nyt editorial board, I hope all these comments have shown you are wrong about asylums!
3
Since we're all aware that what's killing our kids at a shocking pace is mental illness, I propose we have Gun Asylums; places where those too terribly ill to live in decent society (which we always seem to discover after the terrible fact) can be safely sequestered yet still enjoy their god-given right to limitless guns ad ammunition.
We should staff the place with NRA members. Kind of an initiation to the wonders of psychiatric treatment and an awesome display of the power of the second amendment.
1
Are the mentally ill better off living on the street? Does the general public benefit from the mentally ill living on the street? We have the means to provide health care and pyschiatric care in a variety of facilities based on the nature and severity of the illness. It benefits all society to do so. Confinement should not be based on a person's willingness to enter a facility. I once saw a half naked woman sitting on the sidewalk smearing feces on her thighs with one hand while masturbating with the other. The police said if she didn't want to go with them they couldn't force her to.
1
There is no doubt that, broadly speaking, our nation’s psychiatric facilities offer some individuals a measure of stability during extremely difficult periods in their lives. Unfortunately, the current business model that exists within the medical industry has painted psychiatrists into a very tight spot.
Even in hospitals which are relatively well funded, there is simply no reasonable way to expect that any individual in need of treatment will spend enough time with an actual doctor to ensure that any problems which may exist are ultimately dealt with. The answer to this conundrum is not to put more people into cages. All that this strategy accomplishes is getting people accustomed to institutionalization.
Much focus is placed on some hypothetical “magic bullet” that could be used as a preventative method in order to stop future violence, but this concept is a red herring of the deluded. The most effective way to lead is by example, as so many of us are overwhelmingly aware.
1
My grandfather suffered from schizophrenia and was put in a mental institution in 1959 by our family. My family went to visit him once a month for all of his years there until he died in 1984. He was never warehoused, and always treated well, I believe in part, because we actively involved in his care. I believe that is an important component in this conversation.
5
As a child I was "institutionalized", at the time in the 60's all institutions of any kind were pretty much the same as far as chances of being treated well or being abused. The thing that kept your grandfather safe was your families involvement. The abusers in these kinds of places where children are "protected" or sick people "cared for" know full well who has people who will protect them or ask questions about changes and who is alone in the world and therefore safe to abuse.
2
I work with people who are seriously mentally ill and returning from state prison, most because of a violent felony offense. The program we operate provides state-subsidized housing in private apartments, along with support services. While this is an excellent solution for some people, it's a terrible solution for many who cannot live independently in the community, but, because of their criminal offenses, no residential or group home will accept them--we are literally their last resort. These are people without family support who may not able to cook or shop for themselves, who stop taking medication, who may present a threat to others and who are easy targets for crime themselves, and who become horribly isolated, exacerbating their illness. Many have developmental disabilities in addition to mental illness. We desperately need community residences that are willing and able to accept and care for people who cannot live a safe, independent life in the community. Instead they end up back in prison for minor technical offenses at an enormous cost.
2
The most effective system for treating the severely mentally ill should begin with comprehensive services for the less severe mentally ill. Comprehensive services should include treatment which goes beyond mere medication. Such systems were available 60-70 years ago, but just as asylums were closed to save money, such clinic systems were also defunded. Services for disturbed war veterans is an example.
The idea that a severely mentally ill person is an aberration of nature to either be locked away or chemically paralyzed or both is one which became outdated in advanced societies in the late 18th century. If we are not committed to to spending considerable sums to treat the variety of mental illnesses, severe and moderate, we will continue to have the problems we have now.
3
The most recent tax cuts were permanent for the wealthy and temporary for the rest of us. The wealthy do not give a nano-iota about this situation and the rest of us are barely able to keep our own heads above water. We currently have the no-tax increase party in charge which does not bode well for just about anyone except the already wealthy.
1
The tax cuts are permanent only for corporations, who are super-people according to the delusional US Supreme Court.
As a psychiatrist who has worked in the public sphere for most of my professional life, i strongly disagree with the conclusion of this article. The word "asylum" is indeed loaded, but we need to remember that mental hospitals needn't be snake pits as depicted in One Flew Over the Cuckoo's Nest. We need to remember moral therapy, created in the 19th century by a minister to give the mentally ill a sense of purpose and community, two things our present system systematically denies them. If we must talk about cost, and I think we must, we must acknowledge that the cost of not keeping the mentally ill in a humane setting is higher than the humane setting would be with the added danger of unsupervised time. Are the mentally ill dangerous? No, not usually, but due to the very nature of psychotic illness, medication adherence is difficult for them, and with non-adherence comes the inexorable decline to relapse. Do they suffer? They do. Is it harder for them to negotiate society's demands? It is. I believe it is unfair to force them to navigate the burdensome and frankly inadequate agencies that provide less than 100% of their needs. My experience of working in state psychiatric centers in both NY and MA are more positive; patients could get stabilized, learn skills, even recover. We need humane asylums to exist as the places of refuge which they could be.
9
There is a common thread to the first person experiences of these responses: they are close to people who are utterly failed by our current system. Institutions may not be the answer, but group homes combined with mandatory therapy - among a continuum of options - is not only more humane but also more cost effective. My mentally ill relative is homeless with a couple hundred a month of SNAP benefits. Meanwhile, she spends about 2-3 weeks per year in jail for disorderly conduct and 2-3 weeks per year in the hospital for the chronic illnesses caused by her extreme poverty, mental illness and alcoholism. I estimate that she costs the system $50-100k per year while she lives in a tent by the railway tracks. There are other costs, too, like what it has taken to help her daughter grow into a healthy adult in spite of her mother. This relative would need to be mandated to participate in programs that might help, as a key characteristic of her pathology is that she is not responsible for what happens to her. Some version of this story goes on in many, many families.
5
We need to step back and look at this problem with fresh eyes. It's not "asylum vs group home." The needs of mental health patients and their families are complex and diverse. At the front is, housing. The we need facilities for in-patient, committed, individuals that need more than "beds." We need group homes with 24 hour on site counselors and caregivers. We need community vouchers for those who function more and can receive more remote care and supervision.
We need a revision of the laws surrounding the most severely mentally ill and we need families involved the the process of revising these laws. This includes addressing issues of when and how we force care or commitment on a person. It also includes putting in legal requirements for the state to fund this care and housing!
But all of this means we must believe in caring for the most vulnerable in our society. Yet we don't take care of our elderly or our homeless families. And adults who have given years and years of their lives in productive industry are often bankrupted my illness or hospitalization. Sigh.
But the mentally ill often cannot speak up for their own needs. So we must be their voice even in these callus times.
2
As with physical maladies, the continuum of care approach is the only way a compassionate -- and educated -- society can address mental illness.
Case in point: A homeless man in Pittsburgh PA finally obtained long-needed MH care and treatment when trained police officers arrested him for disorderly conduct and took him to the psych ward of a local hospital. There he was stabilized for several weeks & transferred to the mental health unit of the local jail to wait hearing. At hearing, the judge ordered him transferred to a nearby mental health hospital ("asylum") where he was examined and treated for several months until professionals determined he was competent enough to participate in his own defense. Thanks to a county program of "justice-related services," he was placed in a group home which monitors his medications, provides supervision and counseling and seeks to place him in more permanent housing and help him find employment.
"It takes a village" to provide mental health care and without a mental health hospital -- an "asylum" -- staffed with a concentration of trained professionals to assess and address his needs, none of this would have happened.
Unlike most physical injuries/illnesses, mental illness is not usually curable with surgery, better diet, antibiotics or a prosthetic appliance. Sadly, for those whose behavior presents a serious and present danger to society or themselves, an 'asylum' may be the last and only resort.
4
Like many cities, Portland has a large homeless problem. Aside from the lack of affordable housing for the working poor, a sizeable portion of the homeless are untreated mentally ill and/or have substance use disorder. Being homeless in itself poses a danger to self, as do the untreated medical conditions. Yet, well-meaning liberals and misguided judges deem these to be personal lifestyle choices, and don't compel treatment under the "danger to self" language. So our jails end up being "asylums." For the good of society and those individuals, we need more treatment facilities and better commitment practices. We are already spending the money, on incarceration. Let's reallocate that to a more humane use.
8
You are describing a thing in a mistaken way. I think you have made some assumptions and assertions that are untrue.
These untreated mentally ill are there because of the Conservative Christians who run our government refusal to provide Universal health Care. It has nothing to do with liberals or judges and everything to do with the greed of the Conservative Christians who control our country. These folks do not think its a lifestyle choice but they know it is a better circumstance than ending up in an underfunded Asylum or a prison. It was lack of funding or GREED that created the mess that we had in places like Willowbrook, not the innate design of the system or the idea of Asylum. Asylum is "shelter or protection from danger". Not place to hold the helpless so they can be abused more easily.
The substance abuse you mention is probably attempts at giving themselves medical care. The vast majority of them would stop using if they had medical care that served their needs.
The people who control the purse strings simply do not care about the harm. They care that "their" money is never used to help anyone in any way they can possibly avoid helping. Of course they get away with this because they are mostly anonymous.
Where i say "These folks do not.." I am referring to the liberals mentioned.
I cringe to imagine a future when instead of having over-medicated teens in the home, they will be in institutions. In the same way families have lost children with mental health issues to police called to help diffuse a situation, I can imagine parents losing control of their family member to the institution. In short, another form of incarceration where true help is not the end goal, but someone else’s profit is.
3
Beatriz--you tell it like it really is--a lot of comments are in the vein of "well, those people are better off locked away in a mental institution for life instead of jail." What these people are not understanding is that mental institutions ARE jails--just in another form which lines the pockets of those running them.
1
At the root, this comes down to the me-first idealization of the American "independent" meme. Only when we start realizing how utterly interdependent we are, and that as humans we are as much a "we" as a "me" will we begin to make sane policies.
I have been in psychiatric practice since the ‘60’s and strongly believe that the United States urgently needs more psychiatric services. In many areas of health we believe in prevention and early intervention but apparently not in mental health. Services for families, children, and adolescents can make an important difference.
School based services have been cut whenever school budgets get tight. In home services, outpatient services for kids, and day treatment or inpatient services for children and adolescents simply do not exist for too many communities.
There are a number of “people to blame” for the situation.
I have seen federal and state moneys diverted to pave streets. On a daily basis, health insurance companies deny services or approve minuscule amounts of care.
When I tried to expand services in several locations, administrators objected because of the balance sheet..i.e. this will cost more than we can recapture so we should not meet local needs.
Another aspect of this problem: Too many people segregate mental health, believing that it is all about sin, will power and character. Pneumonia is a largely biological illness, and anybody can get it, so are depression, schizophrenia, and addiction. Politicians and insurance companies deserve as much blame as the NRA for some of the gun violence in this country. Asylums may not be the answer because of funding struggles. Dedicated funding administered locally and tight insurance rules may be the only option
4
Its not crazy to talk about bringing back Asylums for psychiatric care. Before the end of his term a bed (or a cell) will be required for Mr. Trump. I'm certain that we will meet or exceed sensible commitment standards required for his commitment and that he will have continuity of care, and even necessary insurance parity. This would not be a controversial solution and it would reflect the great collective will of the electorate and of course meet decency standards. We must act soon. A sophisticated analysis will not be required and this will allow Mr. Trump to live safely while receiving the wide range of care for his severe mental illness.
3
Being forced to deal with people like Trump will drive people crazy.
2
Re: "There just needs to be the collective will, and basic decency, to act."
Aye, isn't that the essential rub... find "the basic
decency to act" applies to far too many of
the apparently intractable social problems this
society resists addressing in any but the most
cursory, indifferent, and therefore ineffectual, manner.
Why that is has a long sad history of course...people
have been sold a bill of ideological goods, all designed
to minimize tax bills, especially of those most able
to pay, that the social collective good in health, education,
transportation, etc. is an illusory fiction designed to
steal their hard earned dollars to pay for meddlesome bureaucrats tending to the needs of the Other, i.e., those different than themselves.
This has been rationalized into an acceptable ethical norm
with which daily lives are capable of justifying the washing of one's hands despite the social collapse all around them. A day spent walking around many parts of San Francisco or New York can easily convince one of this.
It is indicative of the Hobbesian mindset currently dominating the zeitgeist that there is such implacable resistance to organizing around a few simple principles whose implementations would help alleviate the daily struggles just to get by.
1
This is such an important conversation to have. In addition to more medical not criminal facilities we need laws to be changed that enables families to place their loved ones without having to go through the legal hassles that they must go through today. If we have wonderful, community based mental health facilities they will all be for naught unless placement is made easier. Many homeless mentally ill are there because they choose not to be institutionalized, we need to change this. We also need to help families who have out of control and very difficult to handle children and teens who harm and pose threats to family members and other kids in the schools they attend. Often what is precisely needed IS a restrictive environment for these individuals not a least restrictive one in which they can harm themselves and others and often do.
2
Politically motivated explanations aside, isn't the problem here really that there are not enough people who believe that caring for our very ill is a public responsibility rather than the sole responsibility of their families?
1
There isn't even any thought given to the effects of American public policy on public mental health. The general rule is apply cognitive dissonance and hope for the best.
Every single US hospital that receives funding should be mandated to provide a reasonable percentage of psychiatric beds. If someone with a diagnosis of cancer can receive fairly prompt treatment, ie chemotherapy, surgery, radiation, hospice, why does a person with a diagnosis of schizophrenia experiencing psychotic episodes get shuffled off to the local jail or discharged from the ER to a homeless shelter 60 miles away? If the cancer patient was shuffled off to the local jail, we, as a nation, would re-think our priorities.
5
In an era where the focus should be on understanding that what has historically been called "mental illness" and often dealt with in asylums, we should be recognizing that these illnesses are physcial; they are brain disorders. The brain is a physical organ subject to the laws of physics, chemistry and biology, just as the heart, the liver and the kidney are. That the brain's design and function are enormously complicated does not convert it from a physical organ to a "mental" organ.
The NIH has determined in a massive study that many of the more serious brain diseases, such as bipolar disorder and severe depression have clear roots in genetic mutations.
Until we treat brain diseases as physical illnesses they will always be someone's scapegoat and be treated with less money, less research and less compassion and understanding than they are due. This state of affairs only makes matters worse.
Bombard anyone with enough cognitive dissonance and they are likely to become catatonic.
1
Over the past thirty five years, I have practiced psychiatry, in community and hospital settings. My patients and I have confronted the problems, outlined by the editors, daily. Though the details have evolved, the theme has remained the same. We do not have resources to offer even minimally necessary services to those in need. Anxiety, depression, pain, substance use and suicide cost the U.S. hundreds of billions of dollars in lost productivity each year. Could we not save money, in the net, by treatment ?
Why is it so hard to find the collective will to establish adequate services ? Why do we debate this issue only when another tragic incident occurs ? How is it that this major public health problems remains an orphan ?
In the course of the last fifty years, we've made enormous strides in treatment of heart disease, lung disease, kidney disease, diabetes and cancer. Public advocacy for funding for mental health treatment and research is long overdue.
Thank you, Editors, for this reminder. And please help keep this topic in plain view until it is addressed substantively.
6
Good points, who pays? Personally I might benefit from some counseling, but being a private individual I won't be sharing things that I don't want anybody else to know about. Fortunately I have a plan, that is to self counsel and that seems to work.
US businesses loose $30 billion a year because of employees being so stressed out that they aren't productive anymore.
So what if we'd use those $30 billion in order to provide proper mental healthcare to those same employees (and bosses) ... ?
This isn't a money problem, it's a matter of collectively taking responsibility for our well-being, as a society. Or as someone else called it: America's greatness.
We need some form of institutional care for the mentally ill. They do not have the resources to live independently. They are the primary group of people, along with disabled vets and others, experiencing homelessness. The difference is that we do not need to return to "asylums." These were institutions where people were deposited often involuntarily and warehoused for decades. What we do need are housing facilities which include psychiatic support, but are not the old ward hospital model. It is not that complicated. There is just enourmous ignorance and selfishness which prevents us from creating humane and safe housing and living options for the mentally ill. Hopefully this will change. FYI- I am the daughter of a mother who suffered mental illness in her fifties which led to 3 evictions, temproary and homelessness. She was fortunate financially enough and functional enough to find an apartment situation she could afford (although the cost for one room was usurious) in the end. Many are not.
4
The word asylum should indicate a place of safety from a world that is too dangerous for some people to handle. By this definition, those grim fortresses of incarceration for the severely mentally ill in earlier times were not asylums at all, but were more accurately described by the rather vile epithet "loony bins"--places where society disposed of confused people who, though not actually criminal, were too troublesome to deal with. It's rather ironic that the Times has written this editorial as a response to Trump's call for their revival, for when it comes to mental illness he offers a compelling case of a pot calling the kettle black [see Dr Bandy Lee's collection of articles by psychiatrists, "The Dangerous Case of Donald Trump"]. But true asylums, which would offer supportive therapeutic environments for vulnerable people undergoing severe breakdowns, do deserve a more prominent place in the treatment of serious mental illness. While not a panacea, an approach to treatment that offers a refuge to people who could benefit from it deserves serious consideration in any discussion of mental health provision.The mentality of turning fear into power which brought Trump to the presidency is truly a form of madness in itself, and in some way, we are all affected by it. But it would represent a turn towards sanity by us if we were to create institutions that promote psychic healing and self integration--true asylums--for people who desperately need them.
3
There already are insane asylums. Private, for profit in patient psychiatric facilities have arisen to meet the need. I know of at least one in my region in the Detroit, Michigan area. We don't want to go back to the horrors of widespread institutionalization of the 50's and 60's but community mental health is woefully underfunded and unable to deal with really serious cases that require institutionalization. There should be a viable option of long term institutionalization for those patients with serious and chronic mental health issues that cannot be adequately addressed by community mental health programs. Some patients simply need to be institutionalized and that option is not now readily available largely due to long standing budget constraints disguised as compassionate care. The mental health care community must admit to itself that not everybody can be saved. As a result of this error many of the mentally ill who really need long term in patient care are forced to live out on the streets. I think it is cruel and unusual to require those with serious mental health issues to live out on the streets so the sane and hearty can save money.
10
Yes, bring back places for those who need the structured confinement, as long as knowledgeable and educated staff are ready to do the right job.
4
As a clinical social worker who started his career in the public mental health sector in 1972, the essential unworkability and cynicism present in the so-called Community Mental Health Movement were not difficult to see. We were put under tremendous pressure to limit or avoid hospitalizations of patients who clearly needed extended hospital stays and we regularly were unable to help people in the community desparingly trying to obtain needed treatment for their friends and family members. Our hands were tied as were those of the police except in the most extreme circumstances.
And the idea of "community" was especially cynical when applied to those we were treating. These people were the most dispossessed with myriad social, financial, and health problems. The luckiest among them had stable places to live in NYC, but in the interim much of the housing they would have had is no longer available.
It was clear to many of us even at that time that there was never any real intention to make sufficient resources available to these patients and subsequent events have sadly proven us right. I see no reason to expect that this will change in the future.
7
The gap in care for the mentally ill is huge. Psychiatrists are in short supply and people in dire need simply have to wait-for weeks if not months. At one point the only psychiatrist my brother could see was a remote tele communication. I’ve watched my brother struggle with severe depression/anxiety and multiple suicide attempts. Each hospitalization is met with a rapid turn around-out the door as fast as possible and into a 2 week aftercare program. All is woefully inadequate. For people with abundant funds, longer term facilities are available and give them the time that has a chance of making an impact. Just as alcoholics and drug addicts often need a 6 month in house program- SO DO THE SEVERELY DEPRESSED! I truly believe that if these folks could be in a truly healing environment with the kind of reinforcement, life skills, social skills training it would stave off the cycle of spiraling down and ending up on a 72 hour hold in a psych ward. People with depression/anxiety are often socially isolated and struggling in every aspect of their lives but the approach to care is stop gap at best . Bring on a “care community” - not the old “cuckoo’s nest “ asylum.
5
There's a reason why asylums were massively closed down in the 60-80s: widespread abuse, lack of proven methods, and no serious government oversight.
Of course hospitalization is sometimes necessary. My sister is a good example.
She had hallucinations as a young child already, but as nobody ever talked about this issue (not at school, not at home, not in the media, ...) she logically supposed that everybody had this but that you shouldn't talk about it. So she suffered in silence, and then as a teenager started to drink, take drugs, and finally dropped out of college to start travelling all around the world. I was sad to see her give up her studies (she's highly intelligent), but had no idea about what was actually going on.
I only knew, years later, that during her travels she sometimes fell "mysteriously" ill. Doctors didn't find anything - as she still didn't dare to mention her hallucinations, afraid that in that case they'd take away her last sense of sanity and autonomy and coping mechanisms.
She finally ended up in France, where she was hospitalized for more than nine months in a psychiatric facility. It was paid for by the French government, and clearly one of the most comprehensive and competent ones in the entire world.
Today, she's living with a friend, and thanks to sustained government help (financial and other) managed to build her own business and work part-time.
So yes, today proven methods exist. Now it's up to the US government to do its job too.
16
Quality Mental Institutions could help thousands of mentally ill people find a safe place to live. The idea that the Community was going to take care of the problem was a huge lie. We see the results. People living in rags hooked on drugs, dying slowly on the streets. But the reality is it is just an irritation to 'successful members' of Society. They scoff at the homeless and complain to the Police and Mayor of the City to clean up the situation.
1
I do not agree with any of these arguments because neither the President nor other people think about the reasons for shooting.The one and only reason for shooting is lenient laws about gun licences.Anyone ,I understand,can get a gun licence without much difficulty.Moreover how can the asylums help those who are killing innocent people.An example is that of shooting at Charlie Hebdo in Paris where 12 people were killed.Who gave licence to these people who can attack any part of the world anytime without a reasonable cause.Unless people including the children in America change their mindset,this violence wont stop even if there is a asylum in every street of a country.
It is not that easy to get a gun in the states. I say this in the interest of truth, I'm not a gun owner myself.
A valid point about gun violence. The Asylum question still raises hackles because of how poorly the Asylum system was run. Most of the people who were set free from these places that because of refusal to fund them properly became prisons for torture and abuse of the helpless are still alive or their family members who saw the harm are still alive. It is a sore wound here still. Here is one story about one place. And we had at least one of these kinds of places in every single county in every state! https://www.youtube.com/watch?v=YG33HvIKOgQ
As a liberal who studied the problem, Trump is right: we need more psychiatric hospitals. But the problem with community mental health centers isn't lack of money, it is lack of focus: They refuse to serve those who are so symptomatic, they would otherwise need hospitalization. They cherry-pick the highest functioning and off offload the others to prisons, jails and shelters. Families of the seriously mentally ill beg and plead for treatment, only to be turned away.
DJ Jaffe
Author, Insane Consequences: How the Mental Health System Fails the Mentally Ill
Executive Dir., Mental Illness Policy Org.
https://mentalillnesspolicy.org/
7
I have worked in and around the homeless arena in San Diego for over 10 years. I can tell you that many of the people who are homeless have mental health issues. It is my feeling (there is scant hard data) that a majority of those who qualify as chronically homeless have mental health issues. In many cases this goes hand in hand with drug abuse as they self medicate with street drugs to help with their illness.
If we could find a way to help those with mental health issues community wide, we would make a large impact in the rate of homelessness. This would also save communities money as the homeless use the Emergency Room as their doctor. The ER is the most expensive form of medicine and this type of medical help leads to re-occurrence because by definition there is no follow up with the homeless.
We are the richest and most heartless nation on Earth. We spend many times the money on killing people far away than we do helping our own people who are in trouble at home. Somehow we can justify spending $13 Billion on an aircraft carrier while we have people who have no home and when we have children going to bed hungry in our nation. We are a seriously messed up society.
2
All mental facilities tend to be obsessed, probably because of the lawyers, with the possibility you’ll commit suicide. So they are very restrictive places that ignore the great need of the depressed to get
out and exercise.
4
In NY we have 17 large state institutions that house a fraction of their original capacity. In the 50’s, 25 housed 93,000 patients. Today 17 house approximately 3800 - 4200 patients at a cost of around $350,000 per person per year. We also have a system of around 40,000 units of housing for people with serious and persistent mental illnesses operated by nonprofits. The continuum includes Community Residences with 24/7 staff and medication supervision, Treatment Apartments with up to daily staff visits,large congregate facilities with few staff, as well as Supported Housing, i.e., individual apartments scattered in the community for those who need less care. Sounds good but in NYC, a non-profit is paid $17,375 per person PER YEAR to provide an apartment,utilities,staff, 24/7 on call, supplies, administrative costs, etc. In Syracuse-$8,131;Buffalo-$8,899; Albany-$10,052. Community residences are paid between $25,000 and $45,000 per year for 24/7 staff, full medication supervision, rehabilitation services, room, 3 meals, laundry, transportation, and full case management of health and mental health needs. Many clients have significant health issues. Staff are often paid minimum wage.These numbers are very low because so much of the state’s mental health budget is spent on a handful of people in institutions that are not consolidated to reflect the census. We need 7 hospitals not 17. They could even increase the bed capacity. Go to www.bringithomenys.org for more info.
1
We could start by converting 50 percent of every prison into a proper mental health facility.Half the inmates would qualify for the mental health section.It would generate immediate profit and more humane results.
America could solve it's most expensive problems-obesity, drugs,crime,abuse-- with far less expensive mental health care.
3
These institutions should be brought back as less expensive alternative to what we have now.....
3
the current model,at least here in the baltimore area is not working.chronically mentally ill folks are going to ER's and jails when they need structure and security.the revolving door model of treatment benefits no one.
state hospitals must re open with a new treatment model.
4
There are many homeless people on the street who belong in mental hospitals. They are unable or unwilling to care for themselves. They need custodial care, whether they like it or not. We keep hearing about their civil rights. Is it their right to live on the street, filthy and often hungry? Is it their right to need to carry their meager belongings in a plastic bag and be in danger of being mugged by a fellow mentally ill homeless person while they are asleep. Is it their right to be subject to arrest because they have committed a crime because they are homeless and unable to care for themselves. We need mental hospitals to care for those who cannot care for themselves because they are mentally ill.
There have been some school shooters who were known to have dangerous ideas with intent to shoot up schools. Some were interviewed by the FBI. We can't lock them up in prison until they have committed the crime, but their anti-social behaviors could have had them committed. The rest of us have civil rights too. That includes locking up the insane.
2
All these ideas should be considered. But none of them will be and that's reality (the fiscal kind, not the mental kind). If the Democratic Party doesn't take back at least one house of Congress this fall, next year will be an all out war on "entitlements." Medicare, Medicaid, Social Security, food stamps, college tuition grants, its all going on the chopping block. The Greedy Old Patriarchs gave themselves a hugely tax cut this year, and now someone will have to pay for it, and its won't be the 1% coughing up any more dough. Mental health care? This nation needs mental health care but there's going to be no money for any kind of care come next January.
1
The problem with Asylum's then is the same problem we have today.
Say whatever you like there is a large enough percentage of political leaders for whatever reasons you'd like to assert, prove, believe or otherwise choose to accept who REFUSE to tax the wealthy or spend money on the common person. For them The Declaration of Independence founding principle of our basic equality does not apply to anyone who is not already rich.
Regardless of your position the conversation is a moot point if you are not going to focus on properly funded NOT FOR PROFIT Universal Health care and recouping the $1.5T Congress just gave away on our credit card to people who would be wealthy for several generations still if we took 99% of what they have in tax right now.
If the Press is not going to attack and bring down with the truth the myths and lies they helped the GOP promote since Nixon was in office what would be the point of discussing something that cannot be funded properly? It was lack of funding that lead to the abuses at Willowbrook.
Seriously if you are not going to finally confront the lie that let the GOP destroy nearly every part of this nation which the GOP blames on liberals/progressives even though they know the facts and laugh about it and the fools who keep electing them in private.
It has been a long term concerted effort to remake our nation into one where very few people are properly educated in all things and because of that their best efforts do not serve them well.
1
Agreed that the promise of community based mental health care never fully materialized.
There is confusion, however, between mental illness and personality disorders. Trump, in his total ignorance about everything, has no clue about the differences. Like so many of his proclaimations, he is holding a mirror up to reflect himself.
1
I apologize if this is a repeat - trying to post earlier I think I hit "cancel" rather than "submit."
Look, calling for more "mental health beds" is great - if the care is good care. What people don't seem to totally realize about this situation is that psychiatry is primitive. We have a loved one who spent time in what an earlier commenter called a place looking like an Ivy League campus - leafy, rolling green lawns, teams of landscapers tending neatly edged gardens, the main building a beautiful old mansion - all for show. Inside, straight out of One Flew Over the Cuckoo's Nest. We met Nurse Ratched (several of her), as well as staff who couldn't usually be distinguished from patients - they too spent much of their time staring vacantly at the TV in the grimy "lounge."
The doctor would not talk to us (despite our loved one having signed a form giving permission). But I understood why - the treatment consisted of drugging our family member practically to oblivion. There was no "therapy" - absolutely none. The staff were basically prison guards, whose main function was to be sure meds were taken. A couple were decent, caring human beings - many, frankly, were not. We, the family, were treated with contempt.
Let me be clear. This was a posh, private hospital. It was tragically inadequate. I can only imagine what people who are treated in public facilities experience.
It's great to call for "more beds" - i.e., funding. But only if the care is competent and humane.
11
In the 1990s I spent a good portion of time as a misdiagnosed mental patient in such "luxury" private mental hospitals. The reality for patients: junk food and non-nutritious meals, inside fixtures falling apart (oh, but lovely manicured lawns patients never were allowed on)staff which spent time polishing their nails, having affairs with patients (yes, really happened--they were caught), watching TV (staff, not patients), restrictions on guests (we were not allowed to even hold hands with our spouses and other relatives--or we would have infractions/punishments later.) And never mind the physical, sexual, and mental abuse by staff. I could write a book--but never mind, people already have and society has decided such former "mental patients are just crazy and delusional, so let's ignore their experiences."
Btw, one such "premium" hospital closed because the owner was (finally) caught having perpetrated Medicare fraud--several courageous nurses blew the whistle. It was a big scandal in town, but everyone soon forgot about it--and the patients who were dumped into the street with no other resources made available to them.
But, hey, let's re-open the asylums so at least "those people" won't be in our line of sight every time we walk into a Starbucks.
33
I was just about to write "I totally believe you" when I realized you were replying to my own post. We need to hear from more people who have spent time in these places. They're a joke - a tragic joke. The only reason we don't is that the people who spend time there are considered throw-away people by society. They know no one will believe them, or even care. Also, in the case of my relative, they want to put the experience out of their minds. My relative never, ever speaks of it. I know it caused lasting trauma. The cure was worse than the disease. Psychiatry has a lot of housecleaning to do.
This piece is not motivated by a desire not to be bothered by mentally ill people in the community, it is in their defence. Those people are suffering and we collectively have let them down. They deserve our respect and fair treatment for their mental health, vital as their general physical health! Imho the problem is when the majority of institutions closed, there was no plan for how to assist those patients, it was really a money saving plan, at least here in MI thats what they did. Saved some money but caused a lot of suffering in the process.
The mentally ill need to be treated, probably most do not need to be warehoused and overmedicated for convenience though. Not sure what would be best but certainly a rational discussion is a good start. I personally have a dear friend with severe physcological problems and when she was hospitalized her treatment was not up to par imo.
The US has insane asylums. Unwitting people call them “prisons”.
When NC slashed its mental health budget under the guise of reform in 2001, the number of individuals presenting at our hospital’s ER who met DSM criteria for a psychiatric disorder (including substance abuse) went up more than 50% and the head count at county corrections went up 25% over a 5-yr period.
Without access to mental health services, the mentally ill and addicted survive on the streets as best they can until they end up at the ER or jail.
2
What about PREVENT MENTAL ILLNESS, as part of this plan?
Mental illnesses do NOT strike at random. Though some involve genetic sensitivities, the sensitivities alone usually do not cause a problem except when an developmental or environmental failure or trauma has occurred. These can be devastating when they happen during an early window of time, and the child's brain can change structurally and functionally.
The brain develops in function of the input it receives, and brain growth is very rapid in early childhood. I am a CASA. It is no secret that former foster youth, who have undergone serious relational trauma and loss in early life, are very likely to have mental illnesses as adults.
An extreme example of the 'nurture' part of brain development: the Romanian orphans most of us remember. These babies, who were totally deprived of individual attention and interaction could not develop normally and had terrible, permanent neurological aftereffects due to this lack of care.
As USC's Dr John Briere put it, "if we could somehow eliminate child abuse and neglect, the 800 pages of the DSM would become a pamphlet in two generations." Put otherwise, we creat mental illness and mental distress when children do not get sufficient, safe, nurturing care.
Today, 40% of infants lack a strong parental attachment. Secure attachment is a prerequisite of mental health. To reduce mental illness, we need to do better at nurturing and supporting small babies.
7
As a community mental health clinic psychiatrist, I totally agree.
I wouldn't call them asylums but they need something. There are way too many schizophrenics running around the city streets of New York - especially on the subway. Bring them back!
1
We already have "asylums," we just call them prison. Many people formerly housed in asylums are now in jail. This editorial is a ringing endorsement of that policy.
4
We don't need asylums, we already have them under a different name - prisons. A huge proportion of those in prison are mentally ill and by default our criminal justice system has become the means by which we deal with mentally ill people. Of course the fact that it is virtually impossible to involuntarily commit someone until they have committed a crime makes the situation even worse.
3
The horrible conditions in asylums in the 60s are now replicated for the same clientele in for-profit prisons. I read that up to 50% of prisoners have mental health problems. Everything old is new again. Nurse Ratchet is now a prison guard. A country that cannot provide basic health care for its people is certainly not able to develop facilities for a constituency who remain in many American's minds just bad lazy people.
3
If Donald Trump recommends a policy, you can be sure there's a sinister motive behind it. Clearly this President has no interest in "caring" for the vulnerable, but rather in warehousing people who look like they could possibly be dangerous to themselves, or others, and then, presto: problem solved. Keep your machine guns, and I'll lock all the weirdos away for you. Strange, coming from such an eccentric man.
I have to disagree with the board and several commentators that people are safer while institutionalized. I had a cousin who, as an adolescent, was taken to a mental hospital against his will by his family, and was so abused he never recovered - from the abuse. Though he is schizophrenic, twenty years later he is living in an apartment, never once returning to any institution. The potential for abuse of the mentally ill is high, the temptation to take away the civil rights of a fragile person so strong, that reviving this system in any significant way would be one step back. I would recommend reading R.D. Laing, who was responsible for bringing the issue of psychosis out of the back wards and into the light of the public arena. John Kennedy, whose sister, I believe, was lobotomized, understood how wrong it is to unilaterally take away a person's freedom. His humane ideas are based on a personal connection to this issue, and I hope that some day these or similar ideas will be taken seriously by people in government with the power to make positive improvements.
3
I'm afraid the NYTimes is off track here. We need institutions for the mentally ill, alcoholics and hopeless drug addicts. A.K.A. homeless people for the most part. The increasing problem of homelessness which is occurring at the same time as almost every store window having a help-wanted sign demonstrates the issue: many, many people who are homeless can't be employed due to being mentally ill, alcoholics or drug addicts, or felons. We need to help people off the streets so they can be guided to regain responsible lives. if possible; as well as make the streets safe and clean for everyone. No, it is not an easy or pleasant task. Being humane is often making hard choices. Freedom involves responsibility, and the capability to use freedom. A good society uses taxation to solve such problems, but starting with Reagan we chucked everyone from institutions onto the street so as to enrich those behind clean, gated communities, which is shameful.
2
Again, this did not start with Reagan. Do some reading.
Please post some links; that way everyone can quickly see your point. Thank you.
This editorial confuses the needs of the seriously mentally ill with those whose anger, antisocial tendencies, and similar personality deficits lead them to commit mass murder. With rare exceptions, these are different populations.
The first group is ill-served by the shortage of psychiatric hospital beds, and the (usually public) insurance to pay for them. Many such patients want and need inpatient treatment, but can't get it unless they are acutely suicidal. Contrary to the editorial, mental health workers have an incentive to declare someone dangerous even when they are not, so they can get needed care that would otherwise be denied by their insurance. Many denied care are arrested and imprisoned instead. Ironically, this makes prisons our asylums of last resort — refuge from an unsurvivable world — surely worse than the state hospitals they replaced.
The second group, the killers, often cannot be identified as psychiatrically disordered ahead of time. Psychiatry has little to offer, regardless of the facilities we build or services we fund. Background checks and other gun-safety measures can do what psychiatry can't.
8
Crazy talk indeed. Especially coming from a president who has done his utmost to destroy the options for millions of Americans in need of affordable health care, and who places profit above all else.
2
Sure. let's bring back asylums.
They can be privatized. Lots of money to be made.
Jared will look into it.
Easy solution to the mental health problem. Tidy profit.
Must remember to privatize the federal prison system too. Now that I'm stacking the courts, there will be a steady stream of prisoners - great investment potential!
Then I will bring back workhouses and poorhouses. Executive decree. Maybe name them after me - Trump displayed in big letters! Tons of money there - construction, management. Trump Organization specialties, lots of government contracts.
Bing, bing, housing and wage problems solved. Everyone will work for whatever is offered. With no minimum wage, businesses will make billions.
It's only money and when it's good I win and when it's not, it's the Dems fault.
Where's my remote? Time to watch Fox & Friends, plan out my day.
1
The writers of this article are viewing the world through deeply rose-tinted glasses. Every day on my way to work, I pass a dozen or more of these people sitting or lying on the sidewalk, lost in worlds disconnected from reality. They need help. I’m willing as a taxpayer to contribute my fair share. Others are too.
But let’s be realistic. Help at this point will have to be provided on an almost industrial scale. Make-believe about “community care” and “insurance parity” is breathtakingly irresponsible, and little better than the Trumpian twaddle it supposedly stands against.
6
I remember when the ACLU helped a woman sue for the right to not be helped. She was living on a side walk, defecating close to a business that had called to have her picked-up. I believe she 'won' that case as she was not a danger to herself or others. This helps no one.
I agree that bringing back “asylums” is a bad idea. Goodness, some of the mental health facilities that we already do have are already underfunded.
Less than 3 years ago, the news media in my state of Florida reported that $100 million in budget cuts made to our state-funded psychiatric hospitals resulted in widespread abuse and neglect. The conditions reported in those hospitals were shocking and deplorable. (I’m sure that the media exposure of these conditions is what caused our politicians to decide to start putting some of the money back into these hospitals.)
I want to also note that although some of the patients in the community psychiatric hospitals and the long-term state psychiatric hospitals are violent and a danger to others, there’s other patients in both of these types of hospitals that are not. I should know. Several years ago, I was one of these non-violent patients myself.
Also, regarding our spate of school shootings and mass shootings here in America, I do not think that all of the blame should be put upon mental illness. For one reason, serious mental illness affects not just young men but both genders and several age groups. Secondly, many of these shooter’ main mental health condition was depression, and I personally think that condition is not a good excuse for premeditated mass murder of innocent people. Several years ago, I was diagnosed with clinical depression too, and I personally know many others who have as well.
1
"One camp says this profound shortage is a chief reason that so many people suffering from mental health conditions have ended up in jail, on the streets or worse. The other argues that large psychiatric institutions are morally repugnant..."
Both sides you describe here are wrong, willfully so.
People with mental conditions end up in jail or on the streets because the Republican party lied and refused to honor an obligation they had accepted. They single-handedly planted the seeds for what became a crisis of homelessness and people in desperate need of treatment being abandoned.
Back when closing asylums was all the rage the plan was a good one: get these poor souls out of hideous institutions run by immoral and heedless professionals, return them to their communities, provide them with intensive outpatient care and careful follow up.
We were right to shut the asylums, then the Right pocketed the savings and left the mentally ill literally to fend for themselves on the street.
On the other hand, the only grain of truth from the "psychiatric institutions are morally repugnant" side depends on an equally hideous refusal to provide proper care.
When asylums were closed they were filthy, poorly staffed, physically disgusting and dangerous. They were because states refused to pay to make them otherwise. That is, people were chained in century-old basements, naked, sleeping on the floor in their own filth because that's what our government wanted to have happen.
1
LOL, the “Right” sure is clever, being able to steal and pocket money even in Democratic controlled places like New York and California. All their fault, yes sir! Hilarious.
The Right believes in Social Darwinism. They do not believe it is possible, feasible, to have society be otherwise. My conservative mother preached this to me my whole childhood, and is adamant as ever at 91. And, like George S. above, laughs at anyone who idiotically disagrees. This attitude is the at the heart of trump supporters. They laugh off (or worse) progressives, as "snowflakes"; pie-in-the-sky no-nothings-about-"life" - and conveniently forget the Golden Rule, perhaps: but hopelessly for progressives, may also apply Social Darwinism to themselves and "take it like a man". Worse yet, that the current situation is part of the second coming of Christ, and this pre-ordained.
Well, George your right. We all pretty much suck.
But I was speaking of the Nixon administration which got this ball rolling (and which, in retrospect, is looking pretty good) and Republicans in Congress who refused the aggressive community treatment they promised as a condition of closing state institutions.
Yes, it was all their fault, and if you think this is hilarious you prove my point. Yes sir!
Responsibility for the mentally ill should be foisted upon those who bore these children.
In every case of our most current mass shootings ..... parents for many reasons deferred care to professionals who offered guidance and solutions .
The professionals were ready , the nurses were ready at the schools to offer counseling regarding psychotropic medication schedules with teachers and parents , and the guidance counselors had their treatment plans shared with parents and staff. All students are gently exposed to the issues some classmates have daily by teachers and staff through educational materials geared towards age appropriate ability to understand .
Community Policing ( not militaristic behavior and violence toward these disabled folk ) is working pretty well in regions that utilize their criminal justice system to help not condemn individuals and families that consistently spiral out of control.
And then all these “ helpers” wait and wait some more for overwhelmed parents to stop abrogating their responsibilities and finally follow through with consistent attention to help these kids survive and thrive. Parents get it together. Schools are not your day are centers. Schools are not mental health clinics.Schools are not equipped to prevent these killings. Parents and extended family must stand between society and their dangerous offspring. Parents learn about child development and go to parent teacher conferences and all meetings about your offspring.
PARENT!
1
What if parents are themselves mentally ill?
I came of age in the 60's when the psychiatric behemoths were winding down. Shortly thereafter, we would see people in the streets talking to themselves and we would give them a wide berth.
We not only failed to create a community mental health system; at the same time, we abandoned our entire sense of community. Each community used to know its mentally ill members and would take care of them in a variety of small ways. Now we retreat to our McMansions (?our own asylums?) and shut out the unworthy and "defectives".
Today, I might still give a wide berth to someone talking to himself in the street, at least until I saw the bluetooth earpiece connected to his concealed smartphone. (Addiction to technological devices is under active discussion as ANOTHER mental illness!)
1
That might have been true if you lived in a very small town, but I grew up in the city. There's no way I knew all my neighbors. Even if I did know them, how would that help?
1
Call it what you will but the FACT is "asylum" is just another name for jail or prison. We ONLY know how to punish in this country and nothing else. Our mental health care workers are woefully out of date and prejudiced.
2
The debate should not be a choice between 'asylums' or 'community care.' The main problem appears that many brain sick simply lack the capacity to comply with necessary treatment. Treatment that is absolutely necessary to protect the ill from themselves and (rarely) to protect others. Many homeless are brain sick and lives miserable lives in the street. Community care might be available but useless if the sick refuse to participate. The reality is that some brain sick simply are incapable of living independently and require a residential facility to insure these very ill people receive the care and treatment they desperately need. Giving lip service to the 'rights' of the brain sick without also recognizing society's responsibility to provide basic care for those unfortunate individuals who are helpless to care for themselves is just a means to sweep this critical issue under the rug.
3
I agree that bringing back “asylums” is a bad idea. Goodness, many of the mental health facilities that we already do have are already underfunded like it is.
Less than 3 years ago, the news media in my state of Florida reported that $100 million in budget cuts made to our state-funded psychiatric hospitals resulted in widespread abuse and neglect. The conditions reported in those hospitals were shocking and deplorable. (I’m sure that media exposure of these conditions is what caused our politicians to decide to start putting some of the money back into these hospitals.)
I want to also note that although some of the patients in the community psychiatric hospitals and the long-term state psychiatric hospitals are violent and a danger to others, there’s other patients in both of these types of hospitals that have never been violent or a danger to others. I should know. Several years ago, I was one of these non-violent patients.
Also, regarding our spate of school shootings and other mass shootings here in America, I do not think that all of the blame should be put upon mental illness. For one thing, severe mental illness affects not just young men but both genders and many different age groups. Secondly, as someone who was involuntarily hospitalized for depression myself, I think that depression (which was the main mental health condition of most of these shooters) is not a good excuse for premeditated mass murder of innocent people.
2
With a rigorous detailed examination, Donald Trump would have to qualify as the first patient in any new Asylum.
It’s been reported on before, including in the NYT—almost none of the school shooters have been diagnosed as mentally ill, and statistically speaking, people with mental illness are no more likely to commit violent crimes than others, but are much more likely to be victimized.
Had to get that out of the way. Carry on—
1
Let us begin by changing the word 'Asylum' into a more encouraging term. We tend not to match Mother Nature to Climate Change where the latter is often interpreted as a liberal fabrication.
Asylum was once called the Looney Bin in slang. Perhaps some of us have watched 'One Flew Over The Cuckoo's Nest' and have come away feeling depressed. A parent as a rule does not wish to have her child in an 'institution' either.
In 1965, a childhood friend was describing the excitement of taking LSD. In 1969, he was psychotic. In 1971, he stabbed his mother to death in London. He was placed in Broadmoor for the criminally insane where he remained for eight years, while a group of well-meaning people decided he should be released. This was met with resistance by the psychiatrists, but they had their way, and he arrived in New York and was placed in the custody of his 80 year-old grandmother. Within a week, he stabbed her and died by suicide or murder at Rikers Island.
Threatening a youngster by mentioning putting him away is dangerous, and apparently the cause of a student taking his parent's gun to school and killing young children.
On a side note, let us remember Phoenix House and other mental care facilities that are working around the clock with positive results. There are no Insane Asylums, only safety havens for the rehabilitation of the mentally crippled, or damaged among us in this crazy world of ours.
4
Oh my. Community. Asylum. I would like add in another sort of asylum: assisted living.... which everyone thinks is wonderful and is necessary. Have you ever been to an asylum or assisted living NOT in NYC. If you can't drive and won't order a taxi (expensive) you really cannot get out... or as my cousin saidd a gilded prison. I am so tired of the illusions/the mirage -- the supportive and functional family.
Then we replace the notion of asylum (closed facilty) with psychiatric facility (as in a hospital setting),
There are many kinds of psychiatric disorders from fully delusional to Alzheimers to depressed. Not all homeless are necessarily "mental" and many would be happy to spend their lives in a facilty with three meals a day and often pleasant green surroundings (Cue "Rainman.")
I find the language used in this piece rather jejune - and the arguments strange to say the least?
Are the "mentally ill" in jail drug addicts? sociopaths? (plenty of those out there running things in DC -- now there's an idea.)
So far as the kids that kill their classmates.... the last one supposedly was unremarkable.
BTW why not an editorial on how society will pay for all kinds of help for people (no just those in DC leading gilded lives) -- and instituting taxes that affect only rich peoples' toys?
Disingenuous bokum. Flabbergasted.
Finally.
One step closer to my dream. I open the Sunday Times to find, on the cover of the Magazine, this headline:
The Incidence of Untreated Mental Illness in the Adult Population of the United States: A Five-Part Series.
2
No we don;t need "asylums,: and no the need for mental health assistance is not because of school - and other shootings.
However, we do need some form of intervention - when there are mental health issues identified - which is more easily accessed and provided as a matter of course when schools identify struggling kids. A recent conversation with a friend who had taught kids with learning problems - but who sometimes had multiple issues - identified many who had died before age 30 because of: drug/alcohol overuse, and car "accidents." None attacked classmates -- they don't show up in the news. But they should have had more services provided continually.
Yes obviously we need more community services. But we also actually do need longer term care and treatment situations because when there is an emergency, there should be something beyond letting families struggle with impossible situations, or waiting for someone to be found in terrible shape on the streets, or arrested and thrown in jail.
Ie we still may need some version of a congregate care facility . . . while we work on getting more community services including housing . . . not something that is going to happen in the near (political) future . .
Asylum is a loaded word - - - but we need central facilities designed to be more or less permanent homes for seriously mentally ill people.Not because they are going to shoot others, but because they should have humane treatment
1
A huge problem in mental health is the lack of qualified providers. During the "great recession" many people suffered from depression and despair, but there simply were not enough mental health professionals available to provide needed care, even in health care systems that covered the expense of such care. There is also a looming crisis of other health care professionals as current physicians age and retire and younger people seek professions which have better hours and pay. Among other things we need a government which supports education and training for health care professions and provides fair pay for a very demanding job.
Thank you for the long overdue consideration of this issue. We must face several major issues. How many acute care hospitals have been allowed to close their inpatient psych units, both adult and pediatric? How many psych beds now exist in each community? Parity must be enforced. Mental illness is an illness like any other and one which needs supports and aftercare like any other. The state hospital system also needs to exist. There are people who cannot make it in the community and who are terrified to be released. They need the asylum and some threaten suicide if discharged. Some of this is about the trauma they experienced before their hospitalizations when living in the community, some of it from the lack of skills to survive, some from loneliness. Major mental illness usually starts in late adolescence. Patients who end up hospitalized for years lack community living, educational and job skills. The stigma is being mentally ill runs deep and may be one of the biggest barriers to living in the community. If your safe peer group is other psychiatric patients, it is hard to imagine yourself living among others and being accepted. Private therapists who commit to working with this severely mentally ill population in the community need to be reimbursed a reasonable fee. Medicaid reimbursed $36 for a 50 minute session. Other private insurances panels are only slightly better. No one can keep a therapy practice open with that level of payment.
1
I worked in the mental health system as a Psychiatric Social Worker for over 35 years. I agree with this article's assessment of that system. After deinstitutionalization many innovative community based programs were developed in our state: Intensive Case Management, Extended Acute Care, Group Homes, etc. As time went on funding for these programs was gradually decreased, long waiting lists developed, caseloads increase, leading to more burnout and turnover of staff, time and resources to adequately supervise, train and support staff declined. (Many agencies still have Clinical Supervisors but their role has devolved to assuring that therapists document their work correctly so the insurers will agree to pay.) Unless as a community we decide that we are in this together and have a collective responsibility to care for those less fortunate and vote to provide adequate funding for mental health no reforms however cleverly designed will solve the problem. Indeed the asylums developed in the 19th century failed not because the design was inherently inhumane but because funding failed to keep pace with the increasing numbers of patients.
4
Money may indeed be a prime issue, but it is not government alone that has caused this - the psych profession must also bear it's share, for too many practitioners have found it to be far more lucrative and enriching to engage in the "pill pushing" mode of "treatment". This group has also muddied the waters by leveling all mental health issues into one level - it doesn't seem to matter if one is truly dangerously deluded versus simply unhappy with their life (a syndrome for everyone!) lest we have to deal with the less profitable one on the high end rather than the "I need a pill" (for years on end in many cases) set. Finally, we need to be honest and admit that psychiatry is not as precise a practice as general medicine, where, say, cancer is cancer but mental illness diagnosis is, well, fare more fungible.
2
We may be beyond repair here. We could bring back institutions. However, if things keep going as they are, I can guarantee you that these institutions will be privatized and the mentally ill will be one more resource to be mined for profits. There’s gold in them there hallucinations.
4
The problem all along has simply been a lack of serious commitment to the use of public resources to address mental illness. In the old asylums, we had cruel and unjust warehousing of people we didn't want to deal with. They were not only the mentally ill, but also grandma, when we didn't want to take care of her any more.
Then we had an unholy nexus of liberal and conservative ideologies in the form of deinstitutionalization. Liberals preached self-determination to the extreme, such that if someone is not immediately suicidal or homicidal, then no one has the right to over-rule her "choice" of living with untreated mental illness on the streets. For conservatives, it's all about the money. Closing mental hospitals is a huge savings, and without a state-owned facility as a focal point for financial obligations, the scattered public funding sources for community mental health can be whittled away over time, using the inherent insufficiency of the scattered approach as the reason not to spend public money on it.
The result is the mind-boggling crisis of homelessness we see in every community across the country. Instead of addressing mental illness, we spend billions, again with a scattered approach, failing to solve homelessness.
The problem remains the same as it was eighty years ago. We have a lack of serious commitment to the use of public resources to address mental illness. Until we focus on that, we'll continue to move the pieces around, wondering why nothing works.
2
Homelessness is also driven by lack of affordable housing, a minimum wage that is not a living wages, and criminal histories that restrict people from available units. Discussions about long-term institutionalizations of the seriously mentally ill should not frame it as a solution to homelessness. Mental and physical health often significantly deteriorate as a result of homelessness.
1
Yes, there are other contributing factors for homelessness, and no, properly addressing mental illness will not solve all homelessness. Nonetheless, the abject failure to deal with mental illness obfuscates those other causes of homelessness, making the wage and housing issues seem all the more impossible to solve. Remove the mental illness factor, and homelessness becomes all the more obvious as an economic issue.
First, thanks for this thoughtful editorial. My professional experience allows me to say that this is not rocket science nor light years away. That said, we want our problems to have cures, and no one goes to medical school to have a practice full of people with chronic diseases - which practice turns out often enough to be. We should stop promising cures that will enable ill people to return to be functioning taxpaying citizens. Progress and research are wonderful and AMI is terrific for a number of reasons. We used to put mentally ill people in warehouses, now we fill our prisons with black males and are debating how many foreigners to keep out. There is a non scientific, non medical principle involved, and it has to do with sharing our blressings with people who, through no fault of theirs, have fewer blessings.
10
I disagree with their "sensible comittment standards" statement on the incentive to not admit. I'd like to see the data that supports this assumption they are asserting as fact. As we pointed out here in our Health Affairs post (https://www.healthaffairs.org/.../hblog20180329.955541/full/ ), there might be provider-induced demand (i.e., some facilities admit people without proper justification, and they profit). We only know if it gets investigated, so it is difficult to describe what the actual trends are when it comes to their first assertion -- unless there is magic data out there I haven't come across yet. So, yes, some folks might be turned away who really need it (or board in the emergency department), and this likely depends on the patients' characteristics (including generosity of insurance payment, because there is an industry here) --- but it certainly isn't the only incentive and should not be asserted as an overall fact (it is more nuanced). Further, in response to where that statement is true, there is a lack of evidence for the effectiveness of inpatient psychiatric care and a lack of monitoring of quality/accountability --- so how can we even pretend to have a debate about inpatient psych comittment/expansion without knowing what is currently going on inside those facilities and how it impacts folks (does it really make people better, on average? Are some people actually hurt during their stay (this we know is true))?
2
You have no clue, if you have ever tried to help someone with smi get treated you would know this “system” is splintered, nonsensical and does not care about the suffering of these poor persons
We should study the efficacy of inpatient tx if it is lacking, but I think we can assume that it is better than unstable people with SMI being on the street or in jail.
Don't CMS and Joint Commission oversee/ certify psychiatric facilities?
We would (rightly) have an absolute fit if someone with other brain disease (say, Alzheimer's) were roaming the streets or in jail, but we think nothing of it if it's someone with SMI.
Are you suggesting that it is uncommon that patients are turned away from inpatient tx when needed? I am a nurse and a mother of a son with SMI and I can echo with strong anecdotal evidence from the caregiver community (and to a lesser degree personal work experience (since I don't work in psych or ER) that it's very true -people get inadequate tx/admissions.
The lack of- & inadequecy of tx is appaling; in fact, I'd call it draconian compared to other medical conditions' standards. Try getting on a caregiver group online. It will be a disheartening, depressing, &, to the first hand SMI exerience-ignorant, eye-opening read.
Many times, those suffering never even GET to a hospital for evaluation. One example, off the top of my head: a caregiver reported that her adult child with SMI & suicidal intent was starving himself to death, and hadn't eaten for a prolonged period. Neither EMS nor the police would transport him to a hospital. And that is a person WITH a caregiver that is advocating/ trying to get treatment. Nevermind the homeless and incarcerated...
A few months ago, there was a very good long form NYT article about a young woman who was struck with severe mental illness while in college. She literally died on the streets. She died while sitting the ground on a sidewalk, and there was no suggestion of substance abuse. The article investigates her life, attempts at treatment, and how she got to that very sad point.
As a medical (and specifically mental health) professional, that story resonated with me. I’ve treated many patients like her both inpatient and outpatient. I have found that for some people, outpatient treatment simply isn’t enough.
The moral test for me is “what would I want for my family member if they were this ill?”. The need for stable, safe, long term treatment for patients that have proven they simply can’t make on their own is real.
30
This country desperately needs an expansion of Assertive Community Treatment (ACT) teams, not an increase in asylums. These teams have a psychiatrist, nurse, and social worker who meet people with serious mental illness in their homes or even on the street. These teams not only provide medications and psychiatric care, they also assist with employment and housing. Since this model began more than 40 years ago, research has shown that ACT teams keep people out of hospitals and institutions, increase the likelihood that they can live independently, and significantly reduce healthcare costs by preventing costly hospitalizations. While many states have ACT teams, there is a serious shortage across the country and many of my patients (I’m a psychiatrist) who would benefit from this, wait years to get on a team. We need to spread the word about this desperately needed care model for some of our most vulnerable people in our society.
11
Reagan was in this context a manifestation of many, many American's refusal to pay to help others until that same problem strikes them. Then they cry, "Oh, Uncle Sam, please, please help us!"
A society can be judged by its treatment of its least fortunate. Here, in too many cases, we favor the most fortunate.
I live in Seattle, near more than a few homeless encampments. Let me tell you, there are many mentally ill people afoot living in the cold and damp tent or cardboard. Many, perhaps most of them, don't cause trouble. But some do commit crimes to the extent that one is wary around them, even if they may be perfectly safe. One doesn't know.
Something more, much more, must be done to help them.
13
I have been a psychiatric nurse for 46 years, most of them as a nurse practitioner in the city of Detroit. I practiced before the state hospitals closed, and after they closed. The quality of care has gone steadily downhill since longer term care facilities closed. Money is indeed a problem—it did not go to comprehensive outpatient facilities. But a far worse problem is that a large number of patients with serious and chronic mental illnesses, particularly schizophrenia, are simply too ill to live outside of a structured setting. And part of that illness is the inability to recognize that they even have a mental illness. So they see no need to follow up with an outpatient facility if it is even available, and see no need to take their medications, especially with the unpleasant side effects they create. So they self-medicate with alcohol and street drugs, and become vulnerable victims of crimes themselves. And they cycle in and out and in and out of very expensive acute care hospital facilities, getting medicated, discharged, returning to the street, and the cycle begins again. True, we do not need the abusive 1000 bed behemoths we used to have, but we need many, many therapeutic long term care facilities for people who are simply too ill to survive on the outside or need more time to get to the point where they can effectively utilize outpatient facilities. Re-opening smaller, therapeutic long term faculties is the ONLY solution to this ineffective and expensive treatment.
38
hear hear
thank you for your measured response.here in maryland the state hospitals have been shuttered except for forensic patients.
the issue becomes that chronically mentally ill people need structure that cannot always be provided in the community.the state hospitals have to re open and re structure to provide care with a forward thinking model.
9
Agree 100% - anosognosia... you can't reason someone into treatment, who truly doesn't understand that they are ill ...
Again, my example is the grandparent with Alzheimer's. It is (rightly) viewed as neglect if we don't help grandma get treatment... but somehow not viewed this way with SMI (severe mental illness).
3
Locally, a teacher I knew and who was beloved, was shot dead by her adult, schizophrenic son when she knocked on his door to visit with him. So many mentally ill do not recognize their own illness because that is a key characteristic of their illnesses. Letting them choose their own treatment negatively impacts many, many lives and has horrendous costs (financial and personal) to society.
3
I applaud the Times for devoting this editorial space to such a crucial and often misunderstood issue. Having said that I don't think it is helpful to rhetorically divide the "mental health community" into "two camps" essentially pro and anti asylum. I have spent close to 40 years of my life working in various parts of the NYC Criminal Justice System and I think that it is deplorable that Rikers Island has become the de facto largest mental health "asylum" in the United States. In my opinion this has only been permitted because the population directly served is essentially powerless. Sadly, the NYC scenario is not unique but emblematic for the rest of the nation. To deal with this properly we absolutely need more "asylums" (if by that term we are describing professional mental health care facilities that provide beds to those in need of intensive services) and we need more community based services that include properly staffed and supervised transitional housing. Given the resources involved the Federal government must step up and play a leading role in both funding and regulations. From a NYC perspective this is how we close Rikers and enhance public safety while building a more humane society. We should be in the "same camp."
11
The development and wide-spread use of psychoactive drugs in the 1950's and '60s enabled the emptying of hospitals dedicated to treatment and care of patients in need. Coupled with the prevailing incorrect view that all such illnesses were self-correcting, except in the severest cases, and, the extreme lower cost of prescription drugs versus hospitalization, led to the demise of nearly all behavioral based hospitals throughout the country. One serious problem that emerged was that unsupervised out-patients often fail to take their meds.
The epidemics of mass shootings, domestic violence, road rage, opioid abuse, addiction, depression and suicide, among other societal afflictions, provide ample evidence of public policy gone wrong.
Behavioral healthcare in the U.S. is woefully underfunded and neglected. There is no coherent safety net. It is less costly to bury our dead (and heads) than to address this shortcoming in our society.
12
Opioid abuse is in many ways a similar phenomenon to psychiatric deinstitutionalization. Rather than provide expensive orthopedic surgeries and long term physical therapy, patients with chronic pain problems were given long term opioid therapy.
In both cases, pharmaceutical therapy was cheaper and had catestrophic side effects no one could have predicted.
4
At some point society has needs too. In the US, we like to think the individual is more important, but we have gone way too far in some areas. Public health, public safety ought to outweigh the rights of individuals to run amok, or own an arsenal.
10
might be right prescription but absurd argument. what is the point of public safety anyway if not to safeguard the rights of individuals to move about freely? it all comes back to the rights of individuals. remember the bill or rights? the constitution? right. individual right.
2
Not every person with mental illness runs amok. In fact, not every person who has met the criteria for involuntarily hospitalization in a psychiatric hospital has run amok either. Classifying everyone with serious mental illness as a dangerous murderer etc. is like classifying every illegal immigrant as a MS-13 gang member. (Some people with serious mental illness are a danger to others, but not all of them are.)
1
..thank you for providing insight into the mental health issues facing Americans. I think mostly of homeless people I see on the streets, many of which appears to have serious mental illness. But we know the numbers are far larger for those who have shelter - mental illness as one in five adults experiences a mental illness in a given year, and 1 in 25 experience a serious mental illness. The federal, state and local governments have failed, and continue failing tens of millions of Americans with mental health issues. There are millions at serious risk, and have no place to turn.
4
Yet one more NYT editorial about a crucial and urgent issue, and that makes perfectly sense - so much so that you even have to wonder how people could disagree with this.
The NYT is clearly the voice of reason in these dark times, and that gives hope.
So thanks editorial board, I'm looking forward to the next editorial already!
8
The fragmented nature of our insurance market leads directly to this tragedy and won't change until we believe access to medical care is a human right as much as our right to a free, public education supported by the community and free at the hospital or school door. We still have time to get it right.
8
The human brain may be the most sophisticated biological phenomenon on the planet, but it's just another part of the human body. When a body part isn't working properly, people generally get medical care, and symptoms often predicate that care. The brain, however, doesn't enjoy the same luxury as does the leg when ailments manifest themselves. If a person's leg dislocated from the hip and fell in the street unable to get up, would that person be arrested for blocking traffic? Yet when someone's brain isn't working the way it should, the symptoms often manifest themselves in such a way that society punishes, rather than treats a person for those symptoms. I think the first step in deciding what levels of treatment systems we need to erect around mental health is getting away from the stigma and the ignorance that symptoms of mental health problems bring with them. The symptoms of the leg problem don't mimic gross violations of normal social behavior. But because the symptoms of the brain problem does, society views that deviation from social norms to be a poor decision someone has made.
12
This article articulates so well the many issues so many of us live with in the shadows alone. Thank you NYT for re-printing this article and bringing it into the light. My ex-husband is bipolar. I could not, ultimately, live with him, but will never stop loving him.
7
A most interesting, and important, call to action, of a problem that afflicts likely many more folks than we could ever know; not only a human and humane issue we are sorely neglecting to address properly, but a huge loss of productive and self-reliant individuals, unable to participate, let alone contribute, to societal needs...and their own independent well being. And financially a disaster, not only in lost earnings (your figure seems woefully low) but in taxing the community where, by force, mentally- ill patients live. Your mentioning that jails and the streets 'house' more psychiatric cases than proper facilities knowledgeable in treating them is a fact, but there are other all liabilities not mentioned, a glaring problem being that of drug addiction, perhaps an escape from despair and poverty and abuse. And further, that mentally challenged people tend to use medical emergencies too often for their own good, especially if homeless; and premature death is high on the list of liabilities that solidarity (by providing supervised housing) could alleviate. I have the distinct impression that our politicians, unless touched by their own family's mental afflictions, don't have the will to change the current awful status quo only a crazy loon would consider 'normal'. Morally speaking, we can never be more nor better than the least among us. And without a functioning brain to think, a heart to feel, we remain fodder to the whims of our indifference. A heavy burden indeed.
3
As a retired physician who as a medical student in the 60s had clerkships in the best and worst asylums.
The best was in a private hospital run by an order of nuns whose patients were middle class with insurance and who psychiatrists were in private practice. The worst was a state run institution whose patients had mental illness for a longer time, whose insurance had run out and whose psychiatrists were state employees who could not find employment any place else.
The first insitution was civilized the second was medieval.
No one wants to go back to the bad old days but I want more institutions like the first.
It is insane to think that people with mental illness so severe that they would not be held responsible in a court of law for crimes they may commit. That when they are on their own to show up for outpatient appointments and take their medicines as prescribed without first being stabilized in an inpatient facility.
Asylum in the original definition was a place of safety. Those afflicted with mental illness through no fault of their own deserve a place of safety to be treated.
We need institutions and laws that make it easier to commit.
35
Well, O.K.; but I haven't seen the Southern Baptist Convention funding any Health Care facilities. Mental Health clinics could be funded VERY economically, much to the dismay of United Health Care.
2
Some good points.. but really...
when the asylums were emptied, the increase in the mentally ill homeless population surged. Many of these people cannot take care of themselves, no matter what. And what are we to do with them, once family resources are exhausted? Leave them on the streets? Where they are a danger to themselves and a sometimes menace to others? where is the compassion and care in that? what is the burden on the health of a city?
28
Why "but"? The point of the article was that Asylums weren't working but society emptied them without providing a workable alternative. A system of compassionate care is exactly what the writer of the article is seeking.
2
This editorial hits on a few points, but it misses others.The editorial argues the importance of expanding access to care (e.g., expanding continuum of care, insurance parity), which is a "no-brainer". The real challenge is how to diminish barriers to care. What makes it difficult for people to engage in care that they require? Stigma is a major contributor, whether coming from the individual, peer group, or family members. But, equally problematic can be mental illness, itself. When an individual is reclusive, avoidant or paranoid it is extremely unlikely they will engage in necessary treatment. Laws that protect individual rights also ensure that many people will go untreated (because their right to refuse treatment takes priority). Mandated treatment only occurs when an individual is deemed incapacitated (and therefore a court-ordered guardian makes treatment decisions) or is determined to be at imminent risk of harm to self or others. In the latter case, an individual may be involuntarily hospitalized, but only for limited periods of time (until they are no longer a threat to self/others), after which they are discharged and may/may not follow up with required care. Mandated/involuntary treatments require justification that meets very high legal thresholds. Integrated systems of care that incorporate mental health treatment, active case management, home visits, collaborative family engagement, and school/employment engagement may have a shot - but, are very expensive.
8
As a retired physician I have seen the demise of large psychiatric hospitals over my lifetime, much to the detriment of society. And I ask, where did the money go? We should all ask. What I do know is that many people have become multimillionaires from medicine without being a doctor or nurse or researcher of any kind. That is, too many take care of themselves only; and society suffers at every level.
67
There is no "mental" illness. There is only brain illness. To call it "mental" illness is to fall back on on very old philosophical and religious debates about human agency, which predate modern science. While the issue of human agency is still relevant, it is no longer relevant to brain disorders. To call illnesses of the brain "mental" is only one step above calling them demonic possession.
16
I like to this change in perspective. Defining these problems as brain or neurologic issues will help fund care appropriately. The above comment refers to prisoners with renal failure having no problems obtaining appropriate dialysis treatment. The same should occur with brain illnesses as well.
3
Further, change “psychosis” to brain attack and treat it like heart attack or stroke, it is an acute illness of the most important organ in the body
Excellent point.
We have not reached a consensus that all of us deserve the opportunity for treatment of easily identified disease with easily identified treatment protocols. Diabetics , cancer patients, heart patients are on their own if they don't have a job that provides insurance. And the ACA has been sufficiently gutted to make it the AUA. Care is unaffordable.
So if we don't care about the need to grant access to care for people who have easily defined disease with standard treatment protocols, how are we to get to the point that we mandate insurance coverage for the diseases that are less easy to identify and treat?
Mental health treatment often requires the patient to be sufficiently with it to recognize he has a problem and grant permission to treat. It requires compliance. And there are no easy tests - no A1Cs, no enzyme tests, no biopsies - that show the central physical problem manifesting the illness.
That leaves a lot of people out in the cold. Literally, if the family can no longer provide care, or if the patient can no longer tolerate family.
We are not at a point where we can agree that healthcare is a human right, and seek to find a way to make it available to every one. People with serious mental health problems are at the bottom of the list . We have miles to go before we take are of the easy problems. We are light years away from a solution for getting help to people with mental illness.
12
I recall that the superintendents of "asylums" would make their case for budgets by boasting about how little it cost them to house and feed their patients. Legislatures were always looking to cut the budgets for the "asylums", who would complain?
As for the patients, in some of the larger (>8,000 patients) state institutions, patients saw a physician once a year (if they were lucky). They were subject to the latest fads in psychiatric treatment - insulin shock, electro-shock, and then chemical restraints. They were not fine places.
The idea of Community Mental Health Centers was idealistic. Funding for Community Mental Health Centers was swallowed up by the funding for the war in Vietnam. When deinstitutionalization came the "asylums" were closed and the jail populations increased (yes, there is data).
19
It is a big question whether "community mental health centers" are really the solution. Sure, it helps to have care close to where people live. But the downside is that they often tend to direct their care towards the light cases and to ignore those problematic "untreatable" people who are just a bit too good for hospitalization. It doesn't help either that what those problematic people need most often isn't medicine or talk therapy but help with housing, finance, etc.
What is needed most to stop those mass shootings is a climate where people have respect for each other. With his love for "radical solutions" Trump often is more part of the problem than part of the solution.
10
What is missing in this welcome piece is the plain statement that unless society gets serious about paying much more to deal with these illnesses, we may as well forget the whole thing.
Either we assume the huge new cost of treating vast numbers of lower class people with these afflictions, or continue to look on them as disposable.
Humane facilities for their treatment and, yes, frequent long-term inpatient care might well require as much expense as recreating the asylum system of most of the 20th century.
A necessary aside: The worst indecency in mental health is the neglect of minors. Proper in-patient treatment, not throwing miracle chemicals at kids for five days, works wonders in many cases, sometimes with meds as secondary aides.
A serious enough mental illness deprives a child or adolescent of more than a half century of normal life. In place of the joys, charms, anxieties and pains of the ordinary, such young people are condemned to lives of agony, delusions, and the frequent escape of suicide.
Because our society is so chintzy, lethal choices among groups of the ill are necessary.
The selfishness of adults shows itself in floods of expensive care, equipment, and facilities to gain a few months or years of life. We choose such palliatives over decades of mental health for the young.
I'm a septuagenarian, not a punk elder-basher, so listen: this neglect of the young for the slight extension of our lives is a disgrace to my generation.
66
I support your powerful advocacy for minors, and that unfettered inpatient charges for end-of-life care is all about business, and comes from the top.
Long ago, my 18 year-old killed herself after years of institutional care, scores of shock treatments, and a regime of heavy psychotropic medicine.
After her release she was sent to a private school in a small city, almost 200 miles away from where we lived. After years of hospitalizations, she lived in a dorm with no continuum of care, no peer support, no parental support (another story).
She jumped into a deep glacial gorge on the edge of her school's property.
Her death, and the terrifying loneliness she felt prior to killing herself, still haunts me.
I was twenty; I'm now 67. It's an unending sorrow.
17
My daughter has lived with mental health disorders all her life, and getting effective, timely services for her has been very difficult. She has often had to wait 6-12 months for a diagnostic test or to see a psychiatrist face to face. She has been hospitalised, gone to day programs and seen several therapists. The consensus? She has to "think herself well".
Would we tell someone cancer to pretend they were well while waiting a year to see an MD?
Since she turned 18, we have had to start over with everything except, thankfully, the one therapist who treats her like a valuable human being. I was advised to get a medical power of attorney for her, so I can still intervene when she is suicidal, or so rattled by anxiety that she can't speak for herself. I would recommend that every parent of a young person with mental health disorders do the same.
I also care for my mother with dementia, and have for the last 9 years. We are bombarded with information from for-profit agencies offering all the best care at home and away. They cost 3x her monthly income, which at this point is my family income. I had to quit my job 2 years ago to provide care for her because we were neither rich nor poor enough to access other services.
We are not alone. Our situation is a symptom of a rampant profit motive and income inequality. Elders are bled dry for profit, children have no money or power. Caregivers like me bear the load at great personal, physical and financial cost.
15
Thank you for this comment I couldn't agree more. deinstitutionalization began as a civil rights issue, but turned into a cynical ploy to save money by neglecting the mentally ill. Now they're in prison, as I know from years of representing indigent criminal defendants.
I especially appreciate your comment because of its acknowledgment of the greediness and selfishness of adults who want gold plated medical care for themselves but want to skimp on mental health care and education for the young. So much for the greatest generation!
7
The debate must focus on the best medical and scientific practices - NOT money. We opened to doors to our 'asylums' 40 years ago not because of concern for patients and their integrity as humans but because states wanted to save money. The medical arguments were post hoc justifications.
For some, that made sense. For many, it caused great harm to them and their families. Let's get it right this time, a priori.
26
As a general rule, the severely mentally ill cannot work and are thus covered by Medicaid and Medicare. Elderly people with severe mental illness generally fall under the diagnoses of Alzheimer's or Dementia.
Supportive Housing Services is the Gold Standard of Care: a safe living environment with on site supportive services.
Jails have become the default housing and treatment option for the simple reason that is the only place fully funded in nearly all American communities.
The issue of Mental Health treatment is fully dependent on our National need for Housing the poor and disabled, and funding health care for the poor and disabled.
32
Supportive Housing sounds great on paper but nobody wants it in their neighborhood. Having lived in a neighborhood that street people came to enjoy living in that has gotten better due to action on the part of the Community Group I surely don’t miss have been chased at 5 pm, the all night drinking and drugging that kept lower floor residents up all hours and having to walk an extra few blocks just to avoid the panhandling I say “no. Not in my neighborhood. If you think I am being heartless just try living the way my neighborhood had to live.
2
John, I’m so happy to see that you are still working for the well-being of the poor and underserved. Please see my post for an explanation of my belief that we do need long term care facilities for those who require the kind of structure, protection, and support that only those types of facilities can provide. Good to be in touch with you again.
I was involved with mental health clients in the 60's. Out patient state and county facilities were formed to treat and care for the patients who were discharged. Quickly those health care professionals found it was more rewarding to treat patients with less serious conditions who were living in the community than those who were discharged.
Those discharged often ended up in private nursing homes where the care was/is deplorable. Or they ended up on the streets, or in jail or homeless shelters. Never did they receive the medication and treatment that they deserved.
I also sat on several commitment decisions; patients the mental health staff thought were dangerous to others. They were always found not to be dangerous by the judge, who had absolutely no training in mental health.
Not much has changed since the 60s. As trump would say, SAD.
20
Agree with the editorial.
However, without civil commitment to care, including out patient care and the use of psychotropics, we'll see only minor improvements.
Americans will need to move beyond romanticizing homelessness and taking pride in "dying with your rights on" and accept commitment to care
as the loving and humane act it can be.
7
"There just needs to be the collective will, and basic decency, to act."
This says it all. The dumping of mental patients shames us all. Without adequate support, the mentally ill become homeless, drug addicted. I've personally known people who died as a result.
Furthermore, the rules for commitment are absurd and leave ill people without the care they need.
But, as you say, the solution is not to return to warehousing, but to have a range of treatment options suited to the condition of the patient. Society reneged on that commitment because it costs money.
26
So much to say on this topic...was surprised and pleased to see a NYT piece shining a light on what has been a horrible situation for at least the past 20 years. Aside from institutions for the chronically ill - go to any city emergency room any night of the week. Mental health patients are often stacked up, waiting for the few beds available. They can literally be hospitalized in the ER for 2-3 days. It really comes down to money and the fact that the mentally ill are not a voting or contributory constituency that politicians care about. We did lots of bad medicine in the 50s - that doesn’t mean we stopped trying. We can learn from mistakes and provide this population with a SAFE place to recover or even reside if they are unable to manage the outside world. The article did not mention Assertive Comunity Treatment (ACT) - a community based team that tracks the most seriously mentally ill patients in the community and helps them with life skills, provides meds (sometimes daily in person) to minimize hospital time. Unless and until we really look at this problem and commit funding for appropriate treatment - nothing will change.
29
it is an important error to compare tests for visual or hearing problems with early assessment of mental health problems. The "clear" cases are only clear in hindsight. When summarized in a concise story, the indicators are always clear. What is never clear is exactly which individuals should have noted which symptoms at what point and exactly which actions would have made a constructive improvement.
4
As is often the case, the problem isn't in the halls of power, it's in our living rooms. As long as Americans continue to view "mental illness" and "addiction" as challenges to be feared or abhorred, a solution is unlikely.
A simple test: which of the following would you be least comfortable sharing in a social gathering?
My son is being treated for a respiratory infection.
My daughter broke her arm last week.
My son has just been diagnosed with bipolar disorder.
My daughter is celebrating two years clean & sober.
28
Quite so. Let's examine, however, how the word "cancer" has evolved from being taboo, to being widely accepted. The same living rooms that whispered the word cancer can learn to speak about mental illness and addiction, especially now, as we are learning so much more about brain function.
6
Our Mental Health problems have very little to do with "Insurance Parity"; It is the lack of GOVERNMENT funding, state and federal. The "Community Mental Health Centers" we didn't build in the 1970's and 80's; And the Funding to support them.
The successful solution not being discussed is "Permanent Supportive Housing" Which would represent significant government Spending and require political will to override the NIMBY's (Try tying the requirement to the Urban Development Grants they WANT).
Without the Permanent Supportive Housing, we will continue to "Institutionalize" our mentally ill in our Jails and Prisons.
And ALL of this is hypothetical as long as the Republicans are holding the purse strings. You would think they would be interested in the savings on Jails and Prisons, but can't get past their active ignorance on this one.
Unless people have direct exposure to a family member or close friend suffering these problems, no one votes on this either.
19
Unfortunately this is not just a purse strings issue.
Yes, funding is woefully inadequate. But also funding that has been attempted gets gobbled up in legal fights as local residents try to (and often successfully) fight the placement of treatment facilities, and supportive living facilities in their neighborhoods. The NIMBY attitude makes it much harder, and more costly, to develop a competent network of care for mental illness and substance abuse.
7
Whatever the strong solution, we must arrive at it. This is the civic issue that defines a society.
If there is one public experience that we all have had in recent decades, that drags all of us down into helpless depression, it is seeing the obviously incapacitated let loose to live on the streets. We cannot solve this problem with general “homelessness” policies. We cannot solve this problem with jails. We cannot solve this problem by blaming Ronald Reagan’s prosperous policies, who does deserve blame — but doing so does not help to solve this shameful problem.
We know better.
We must know better.
10
“Let loose” is an appropriate way to talk about an animal. “Abandoned” might be a better way to talk about the neglect of a human being who is sick to the point of not being able to function on his or her own.
In general, the way that we talk about people who have mental illness tends to be quite dehumanizing. People who have mental illness are everywhere. We are your coworkers, your friends, and your neighbors. We are especially vulnerable, just like anyone with chronic illness, to losing jobs and losing valuable healthcare, homes and other support. We did not choose our illnesses, and we are worth protecting.
Many comments here, such as the one I am responding to, are quite right and supportive, except for the underlying dehumanization that makes some of us feel quite a bit of pain to the heart and soul. Take care, all. This is such an important discussion.
1
I have to agree with a post I read, starting with the thought of looking to other countries in Europe, such as Scandinavia for
guidance. Their population comes before their profit incentive. That said, we have to attack the problem as best we can, which isn't saying very much for this country. Prisons are full of people with psychiatric problems. That has to change. Working for a time as a psychiatric nurse was insightful for our lack of treatment, follow-up, and supportive services. When insurance coverage was up....usually 3 weeks, you were miraculously cured. This system meant, in effect, you would fend for yourself until the next commitment.
I don't object to the term asylum, it also connotes a place of
security and safety. Bring them back with monitored and modern facilities, and all the resources at hand to make it a
place of care for those who cannot care for themselves.
22
Many people with psychological problems require long-term medication, counseling, and help fitting in their communities (housing, work, socialization). And they need timely intervention when their condition reverts to obvious troubled conditions. A little more proactive care with a bit of coercion, carefully monitored, can do wonders to enabling all to live decent lives. Insisting on absolute hands-off until full imprisonment is absurd, like supporting life for all fetuses and then taking away life-support for them after birth.
10
When we closed the asylums, we threw out the baby with the bath water.
We can never get back those spacious grounds and buildings that were the old asylums. Today, when city leaders suggest a location for a new mental health treatment center or supportive living apartment complex, the neighbors all complain and vote it down.
We could have improved the old institutions, modernized treatments, added outside independent agency oversight to provide patient advocacy, and introduced more transitional services to make it easier for people to leave. We should have done a slow transition toward more integrated community treatment.
Instead, we kicked patients out of spacious places like the Camarillo State Mental Hospital (now California State University, Channel Islands) with its Mission Revival adobe buildings, gardens, fountains, and dairy farm--and sent those patients to the asylums of our crumbling inner city streets and our brutal maximum-security prisons.
I would far rather live at the old Camarillo State Mental Hospital where I could walk outside in a beautiful garden than be alone at night on the streets of downtown San Diego or in a cell in a barbaric U.S. prison.
168
I’ve seen too many cases where those with decent housing where they are comfortable made worse when they are taken from the familiar and placed in even the best psych. facilities.
These people need psychiatric care in a place they’re comfortable - return the house call as a mandated insurance-covered portion of a shrink’s schedule.
If the number of competent physician candidates > number/available space at medical schools, build or enlarge, and make med training rational, without hazing new doctors with 48-hr. Intern/resident requirements that hurt both students and patients to make teachers’ lives easier. Make med school free, and all physicians work 2-4 hours a week at a free clinic and making house calls to patients who need them
Require Insurance programs to allow a patient to have an introductory session with 3-5 shrinks to avoid Dr Fel’s Syndrome. Even those held due to threats to others/selves.
Only forcibly hold, in comfortable settings, those who meet those criteria. Homeless psych cases need homes first, then treatment - not group hones, for most, but comfortable apartments even if the doors need be locked 10 hrs. a day.
Wealth controls now. If John Hinkley’s parents were not well-off, their son, a normal person when treated, and who needs enforced dosing and regular med adjustment, would be in prison for life.
Require psyc. care include cognitive therapy though outward behavior can be controlled with pills.
Those are just starters. Progressive graduated tax first!
9
As with most issues, my first thought is: look to Scandinavia, Germany, Japan... what I refer to as ‘civilization’... I‘d bet dollars to doughnuts that they have extant solutions that include, and require... a belief in government, progressive taxation, equitable growth, healthcare for all, unions, living wages... in short, a commitment to the well-being of their society and their fellow man.
The ethos of America is Greed. We ARE an asylum.
112
"The ethos of America is Greed. We ARE an asylum."
No the Ethos of the Republican party is GREED. Yes the US is an asylum.
5
A large number of homeless here in Portland appear to have major substance abuse issues and exhibit very erratic, self-destructive behavior. I'm no doctor, but I'm guessing many would be considered "mentally ill". Whether the drug abuse causes, or stems from, mental health issues, the 2 are clearly intertwined.
Is it sensible to discuss policies on treatment of mental health without also addressing drug abuse? I think not.
If homeless people, who are abusing drugs, costing society, and also being easy prey to drug pushers, were to be forcibly moved into well-run, health-oriented institutions, what would be the impact on society as a whole?
Pushers would lose a sizable portion of their clientele.
Petty crime would be reduced.
Quality of life for the drug abusers would be improved. At least some might eventually be able to return to productive lives.
Neighborhoods in our cities that are currently unattractive would become more desirable and open to improvement.
What are the downsides? The loss of civil liberties of people who are abusing drugs and their bodies, opening themselves to the spread of communicable diseases, and who will probably die decades earlier than they should have.
18
Of course, even if we institutionalized all the mentally ill, but were unable to identify or do anything about the causes of mental illness, in a generation would we be right back to where we are today, with a whole new crop of suffering people?
2
With regard to health care in general, many other nations provide better care, cover everyone within their borders, and cost less than our disgraceful for-profit system. We have lots of good examples to choose from, if only the politicians from both parties weren't in the pockets of the insurance and pharmaceutical industries. I'd like to know which, if any, of those nations have a better mental health care system that we could emulate.
14
Thank you for highlighting this essential issue!
A central theme in the history of US mental health care has been cost-shifting, literally "passing the buck" to avoid giving needed resources to care for vulnerable individuals. The Medicaid exclusion for freestanding psychiatric facilities is an example -- Medicaid does pay for psychiatric care in general hospitals where the state share is 25% vs. 100% in a state hospital.
We need more long-term psychiatric beds. But they should provide humane and high quality care.
We need more community resources. Few community housing options exist and most have requirements that most adults would find stifling. Emergency shelters are a costly alternative. Housing First (https://endhomelessness.org/resource/housing-first/) is cost-effective and can provide needed support.
We need to rein in the cynical policies of insurers. Even with parity in benefits, they still deny paying for care by claiming it's "not medically necessary." Clinicians spend valuable time appealing these decisions. And this is a bigger reason than commitment laws for not admitting seriously ill individuals.
We need to reduce paperwork burdens imposed by states, Medicare/Medicaid and Joint Commission that are unique to behavioral health. There is already a shortage of trained staff and wasting time on duplicative documentation is silly.
Most of all, we need to consider how we would want to be treated and then reform funding and programs accordingly.
27
Anyone interested in this subject should read the following article:
Harcourt, From the Asylum to the Prison: Rethinking the Incarceration Revolution, 84 Texas Law Review 1751 (2005). http://chicagounbound.uchicago.edu/cgi/viewcontent.cgi?article=2470&...
Essentially, the brouhaha about "mass incarceration" that exists in America today misses a key point. In reality, today America institutionalizes the same number of people as we did in the 1950s. Unfortunately, they are institutionalized in jail and prisons rather than mental institutions. As the nation moved to de-institutionalize mental institutions in the 1960s, the total institutionalization rate declined dramatically, which produced the crime wave of the 70s and 80s. Then we built more jails and prisons (instead of mental institutions) and crime declined.
This has been a sad evolution, led by self-righteous progressives, that has caused far more harm than good. Now jails are the largest mental health institutions in most cities, and they house people who could have avoided their criminal conduct, and avoiding creating victims, had we been sensible with our civil commitment policies and maintained a robust system of mental health institutions that could actually help the mentally ill instead of turning them into criminals.
57
I agree with most of what you write except for casting blame on the progressives. It was Ronald Reagan who closed the CA institutions and threw the patients out on the street, then took that same attitude to the federal government. It is the GOP who has a “too bad, so sad” attitude towards most of our citizens who struggle for any reason. Let’s move forward in a bipartisan, solution focused, data based manner.
1
Mental health parity is a completely different issue. Those most in need or inpatient care do not have insurance under the ACA or any other private program.
7
Parity is a big issue. Policies that have a lifetime cap on mental health payments leave people with no other option than to enter a publicly funded program, such as Medicaid and SSI, and are thus deprived of the choices that are available to privately insured people.
Can’t help but regard the characterization as unfair. To refer to institutions that address mental health issues in those who suffer from them and either have or could present dangers to the general public as “asylums” is to conjure the bogeyman of “Bedlam”, or Bethlehem Royal Hospital, the 18th century London psychiatric institution (still active but with a far healthier reputation as a modern psychiatric hospital) and the origin of the word for chaos or madness, in which patients were abused in all sorts of horrific ways when not altogether ignored and left to their fates.
What the country should do, perhaps, BEFORE considering whether to invest more intensively in institutions where mental illness can be treated by professionals who focus primarily on THAT curse, is retire from common usage the world “asylum”. The word itself has far too high an emotional index, and it just clouds the issue terribly.
Many of our laws that seek to protect individual rights against the abuses of bureaucracies are targeted at DENYING power to elites or bureaucrats to stigmatize people in order to impose such power over people. I doubt that the editors’ suggestion that commitment protocols be made friendlier to apparatchiks has much chance of being adopted. That presents a real problem, but it is what it is. To empower officialdom to commit people more freely still would require a level of oversight that could be practicably prohibitive – but it’s an idea worth pursuing.
3
As to far greater investment in this social challenge, we would have to figure out how to pay for it, and where it lies within the range of priorities of all other programs we fund as part of the social safety net that didn’t exist when JFK sought to humanize the system that existed then. And including such costs in Medicaid likely would make that program even MORE fiscally catastrophic to our states, which have robbed investment in infrastructure and education to pay for what Medicaid ALREADY covers.
Another option is to salvage the prisons that we’re seeking to empty of low-level drug criminals for this purpose – they’re already situated in communities that have gotten beyond NIMBY, and they’re already well-secured. Renovate them to be hospitals instead and fill them with medical personnel instead of JUST guards. But, in the end, there is no fiscally sustainable means to address this social challenge but by large institutions that concentrate the afflicted.
4
The U.S. now pays $770 billion for the DoD annually. Perhaps money for these needs can be found there.
I suspect that it would be cheaper to reopen the state mental hospitals in NJ (if the buildings still exist) and staff them properly than to pay for prison space for the same population, especially in private prisons.
It still won't deal with the conduct of the staff. My wife spent some time as a doctor for one of those institutions, and found that child inmates were sometimes left strapped to their beds when they needed a restroom. The staff did not want to interrupt their card game.
I grew up when asylums were common. Now we have at least two problems: a) How do we decide whose liberties are to be slightly or severely curtailed for the common good? and b) How do we go about curtailing those freedoms, and then what? This op-ed describes the problems, offers many obstacles and pbjections, and then punts. Good work!
11
Reagan closed the mental institutions to save money but under the guise of giving persons with mental health issues "freedom." I think persons living in these institutions were like "Yahoo!" Now, 40 years later, it's like "boo." So many promises for community mental health services that never happened. Today's services are so limited, with such low pay for employees pretty much putting their lives in danger daily for about $100/day. I think the ideas in this article are great.
22
The phrase "insurance parity" sounds worthwhile on paper, put in practice won't work. The problem is that unlike with most physical illness, diagnosis of many mental illnesses is subjective. The unfortunate result is that unless we are careful, there may well be large scale overdiagnosis and even abuse, on a scale large enough threaten public funding of medical care in many situations.
The Wall Street Journal, for example, recently reported that at many colleges and schools 20 - 25% of students receive special accommodations during exams due to mental illness such as ADHD, and that the precentage is rapidly increasing. Special accommodations often include extra time on exams. Do we really believe that 20 - 25% percent of the population has a serious mental illness?
We need to put reasonable limits on the diagnosis of mental illness, to accomoadate those truly in need, without opening the door to widespread overuse and abuse and public funding for therapy that may not be necessary.
10
Reasonable limits on diagnosis are indeed needed, but in addition, even among those who have been reasonably diagnosed as mentally ill, it is not good for anybody to favor one group of students over another on exams by allowing selected students extra time. When they graduate and seek responsible jobs, they will still be less competent than graduates who did not receive extra time, and their college grades should reflect that honestly.
6
Alex
"Do we really believe that 20 - 25% percent of the population has a serious mental illness?"
No, but we also don't really believe that all students learn or respond in the same way and that we ought to punish those who fall outside the random and arbitrary limits you choose to call 'normal'.
You honestly think its worth wrecking somebody's life because they read more slowly, think more deeply, are more stressed by tests than some perfect little Johnny who aces every exam but has no conscience, no real understanding, no heart?
Because if you do, you're problem here.
1
Fern
They will not be 'less competent', they will be slower. And probably only on tests.
It would help advance the cause of parity if government and health agencies would stop referring to "behavioral" illnesses. Lumping mental illness into the same category as drug abuse, which does involve some degree of volition, only reinforces the stigma. Psychiatric illness is rooted in medical causes: the fact that the organ involved is the brain as opposed to the heart, kidneys, or pancreas doesnt make "mental" illness less physical. Schizophrenia is no more "behavioral" than Alzheimer's.
63
I agree that there should be parity.
However, substance abuse does result in mental illnessses in several people — not only depression but psychotic disorders as well. If the general public was aware of this, I think it would serve as a good deterrent for people who may be attempted to use or abuse drugs.
On the other hand, several other people develop serious mental illnesses through absolutely no fault of their own. I’m one of those people. (Several years ago, I was hospitalized in a psychiatric hospital for mental illness. But I have never even used much less abused any illegal drugs or even alcohol.).
17
What percentage of mental illness would you say is caused or triggered by drug or alcohol use, and where is the data to back this up? Thank you.
Jerry Brown agrees that much more inpatient care is needed for the mentally ill. Such care, though, doesn't have to be like old asylums. It can be more enlightened. There can also be better community care.
In like 1971 I was at an international conference at the University of Wisconsin on alternatives to asylum or warehousing type inpatient care. All experts agreed the old state hospitals were harmful and inhumane. Right in Madison there was a alternative pilot program that had good results: apartments or rooms for patients in the community with treatment and sheltered work programs with a supervisor for each patient. Most patients would sleep alone, with 16 waking hours under some type of supervision and treatment. The results were impressive. Patients became more productive and involved, with fewer symptoms. They still took meds and had individual and group therapy as appropriate. Many were employed at least part time in sheltered workshops, some in competitive jobs.
The only problem: the cost was about the same as the old hospitals.
Politicians of course were for closing the hospitals--without community programs. And, as you mentioned, the streets and prisons absorbed the patient population. And the cost of prisons and people in streets is more expensive in the long run than good community treatment and work programs. In the short run, of course, it was cheaper just to let patients fend for themselves, without treatment or protection.
71
I was actually a volunteer at that Madison, Wisconsin program. It was called Program of Assertive Community Treatment (PACT) and you’re right- it was excellent!
28
It was excellent, but it was expensive, as expensive as long term inpatient care. It was a failure of our profession not to realize that deinstitutionalization was not about more humane care for the seriously mentally ill, but about cost savings by governments who would give lip service to ACT but chip away at funding so that effective services could never be provided to patients who desperately needed them.
We were naive, or worse, and our patients are suffering for it.
I was in 6th grade and lived in Long Beach, NY during the late 70's. At the time, Long Beach was a pretty run down place, with the boardwalk dotted with abandoned and dilapidated old hotels.
Long beach was apparently one of the places the closing asylums dumped their patients, and they would squat in the abandoned hotels.
Some days we would skip out from school and go down and explore the cold and moldy hallways that smelled of urine and neglect.
We were kids, so of course it was part adventure. But I also remember talking to some of the adults lurking around. We were not mean kids; we were just curious.
It was my first face to face exposure with the reality of how often our society just simply disposes of people as if they had no value, no dignity. Those days skipping school to go to the decrepit boardwalk in the winter still haunt me.
79
" bring back the asylum"
it is unfortunate that the nation's largest mental health care facilities are the jails and prisons. In an article published in the Journal of the American Medical Association, bioethicists at the University of Pennsylvania outline the crisis of mental-health care in the United States and propose a solution: Rehabilitate the ill-reputed institution of the psychiatric asylum. While the researchers praise well-designed outpatient community treatment, they say that this kind of care is not the right solution for some severely and chronically ill patients. For them, “the optimal option is long-term care in a psychiatric hospital.” And they call for a return of psychiatric asylums that are “safe, modern and humane.”
31
This policy of closing large asylums or institutions has been a disaster wherever it has been tried. If you talk to many of those with chronic schizophrenia, these places were asylums in the best sense of the word; a place offering protection and shelter.
As the article points out, promises to provide real community-based alternatives , were never kept. It was never a priority, not only in the US, but in the UK, Canada and other countries. People with chronic mental health problems remain vulnerable and stigmatized. In the US there was this obscene lack of parity in coverage, in other countries, there remained this ignorant attitude about people somehow being able to pull themselves together.
People tend to see themselves as weak and failing rather than as ill and in need of care. Conservative politicians, unfortunately tend to reinforce that attitude . Steve Bannon was quoted as advocating spanking as a way to prevent mental illness in children - this from the man hailed as a genius among conservatives.
It's curious now that gun ownership and violence are now under the gun themselves, we hear about re-opening institutions previously regarded by conservatives as a drain on society. Unfortunately their renewed interest in asylums - which have many clinical benefits - arises not so much from compassion and good common-sense, as political expediency.
However, those of us who work in mental health would welcome more resources anyway. But we should be mindful.
39
I grew up on Long Island, and within a 15 miles were Pilgrim State, Kings Park State, Edgewood State and Central Islip State. These were gigantic asylums which housed thousands of patients. Originally built out in rural Suffolk County, their original intent was to move patients from New York City to a more rural setting. Many of the patients did farming as part of their therapy.
By the 1960s, suburbia grew up around these facilities. After an expose about Willowbrrok State (Staten Island), most New Yorkers learned about the horrible conditions in these facilities. There were all closed down.
Pilgrim State still remains, as a campus for Suffolk Community College, some buildings go unused and are in decline. Kings Park has been leveled and homes will replace it. Edgewood State, which was across the street from Pilgrim State was leveled and is now a nature preserve. Central Islip has also been leveled. Most of it is used for NY Tech, a large shopping center and a stadium for the minor league Long Island Ducks.
These hospitals were scary looking, multi story buildings, with bars on the windows. Pilgrim State was close to Commack Road, so they could easily be seen driving by. Thee property was surrounded by a 6 foot chain link fence, with barb wire. They looked more like jails, than hospitals.
If you ever saw the move "The Snake Pit", it pretty much exposed what these places were like. Hollywood was rather tame to real life.
Now, you get the idea why this is a bad idea.
14
Well, Fairfield Hills in Connecticut looks like the most exclusive Ivy League college you'd ever want to attend. It has its own horror stories. The state shut it down, handed the deed to the the town of Newtown, and a multi-billion-dollar asset is being left to rot. Great fiscal management.
I don't know the right mix of inpatient, community based, and individual treatment. But please don't ask me to uncritically support parity. I've met far too many "mental health professionals" who don't even pretend to be doing anything other than continuing "therapy" for as long as they can extract payment.
10
Many of the mentally ill will never be compliant about taking meds, even if there were a mental health clinic on every single block in the country. It is part of their illness. Many would be far better off being in some form of institution, perhaps even for life, in some situations. At least they will be kept clean, healthy, and safe. Right now, they often are experiencing any of these things.
Families who try to help their mentally ill family members are face with huge problems. Living with them is so terribly disruptive to the family as to be pretty much impossible. But finding help where they can be put in a safe place, is legally impossible for most. So, they end up on the street or in and out of various family members homes until the family member cannot take it anymore.
Right now, the "institution" we are relying on for their care is the prison system. It is totally unequipped to handle a substantial mentally ill population, nor should it be expected to do so.
For a severely, non-compliant mentally ill person, a mental health facility with incarceration is a far better place for that person to be than on the street or in prison.
177
You are 100% correct.
Yes...and the use of psycho therapeutic drugs as an “end all/be all” occurred with the cooperation of a lot of professionals who knew it was fool’s gold. Professionals in the field need to step up and take back their advocation…and maybe, eventually, their credibility in this matter.
3
Many of the mentally ill will never be compliant about taking meds, even if there were a mental health clinic on every single block in the country. It is part of their illness.
My friend Mr. (Ms.) India, that statement is simply a supposition on your part. "Anosognosia", like beauty, is in the eye of the beholder.
1
The wave of asylum closure some decades ago was prompted not by a sense of righteousness but the desire to save money. Indeed, the community mental health systems in nearly every state received no enhanced budgeting whatsoever.
Those who work with the homeless are excruciatingly aware that the vast majority are not simply poor people down on their luck. They are mentally ill-- many psychotic and many others addicted. A further unfortunate truth is that an overwhelmingly large number do not want mental health services-- whether that is medication for psychosis or drug rehab. It is a myth that the addicted would mostly be in recovery if only treatment were available. They want to use.
There are variations of the mental health laws that that would help. So called outpatient commitment subjects the person to involuntary status but allows them to live in the community if they take the antipsychotic medication needed to control psychosis. There is no comparable help for the addicted and nothing to be gained by locking them up.
We may not need more asylums but we need a lot more money for outpatient treatment.
33
I'm not sure that I have enough je ne sais quoi to be talking about this but I'm going to state what I know.
Persons with a mental aberrations do not recognize they are aberrant. For them, it is the norm. Moving out of that 'norm' means stress, discomfort, confusion, and loss. Would anyone, for an example, Joan of Arc, be willing to take any number of pills every day so that she would not have the voices of her Micheal and God in exchange for a world around her that made her feel isolated, lost, and hopeless?
I don't think so.
I realize that many forms of mental illness are living in separate realities.
That is frightening to many people who deem themselves 'normals'.
It seems likely that the more social persons want the less social persons to conform to standards. But to the aberrant it seems more likely that the standards are willfully blinded in their pursuits of flocking.
Just like starlings flock and eagles don't.
Society will never be able to convince many people 'who just don't get it' to join 'it'.
Insane Asylums were never meant to be the cure centers. They were meant to keep the differents apart from the center of culture.
Sometimes, but not always, the differents need and want a safe haven from those center of cultures.
As long as the Culture doesn't demand a cure, but instead provides an access to without threat, then yes. Bring back Asylums, but understand they are to protect those who live between worlds, many others don't understand or can know.
24
I don’t think anyone is seriously talking about long term commitment for people that just experiment the world differently. More than 99% of people with mental health issues don’t need long term hospital care. But when one’s loss of connection with reality creates a demonstrable inability to care for self or risk to others, we should step in and help.
2
"how little has been done to fill the void since they were shut down.. . . Nor does anyone disagree that the “system” that replaced them is a colossal failure."
People are dying. They're helpless, and they just die. Here. In our rich country, all around us.
I've seen police arrest someone just to save him, to get him inside to safety, so he doesn't freeze.
When they come into the courtroom for arraignment, they have been fed and are clean. The prosecutor cuts them loose. Nobody even pretends there was a crime that would be prosecuted.
Even worse, some are such repeats, at such risk, that they do get prosecuted. Putting them in prison is the only way to keep them alive. I have one in mind I worked with, who was so drug-damaged he could not speak coherently. He had no chance. Out there, he'd die. He just couldn't do it. He wouldn't admit it either.
What, do we let them die of neglect right in front of us, pick up their bodies in the parks and sidewalks, because they "want" that?
Utter lack of actual solutions leads us to just make up something, because we've got to do something.
That tears away at our justice system. It fills prisons. It does no justice, and the practice threatens to leak over to outright disrespect of the law by do-gooders aimed at others too.
This is a mess, a very dangerous mess. It threatens more than just the obvious first victims.
127
I know how accurate your assessment is! My relative spends 2-3 weeks per year in jail for minor offenses and another 2-3 weeks in the hospital. If only that cost was redirected to court mandated group home therapy placements. Until and unless the “mandatory” is part of it, she will never self commit. Although she does seem to like all the attention she gets for $5k per day at the hospital.
3
Dealing with this urgent issue is probably the most important steps we can take against homelessness. There is a myth that homelessness is simply due to the high cost of living in cities, but mental heath issues of some kind, including drug addiction, is likely to be a key factor for most who end up on the street instead of moving somewhere that they can afford with a job that they can get.
74
Mental health is a complicated issue. Questions of how well psychotropics can manage some conditions, let alone how to ensure a psychiatric patient takes medication, or how autonomous troubled individuals can safely be left, do not suggest simple solutions.
Gun control, however, need not be so difficult. Of course, Trump fancies it politically preferable to involuntarily commit people than to suggest the limits to firearms which keep most of the world safe from the bloodbaths we suffer.
Guns, not people, are what our laws should regulate.
14
Another popular lefty meme, but not true. First off -- our right to guns is part of our Constitution and our history. The Constitution makes no mention of health care or MENTAL health care. While you may morally feel "health care is a right"....that's an opinion, not legal fact.
Second: those other nations NEVER had a violence problem -- most are entirely different from us -- homogenous, small, wealthy, isolated, etc. There is no example of a very large wealthy nation with free ownership of guns that suddenly went to NO guns and cut their violence rates by 90%. (No Australia is not a legitimate example, being small and mostly white/asian.)
Third: there are ALREADY 300 million guns in the US and 100 million gun owners. It's one thing to flippantly call for "more gun control" and another to very specifically tell us how you will BAN and CONFISCATE 300 million guns from private ownership. Australia is 1/12th our size with only 5 major cities, and no serious opposition to their nation's gun ban.
Fourth: this is more about homelessness than gun violence, as not all mass shooters were adjudicated as mentally ill, or had a history of mental illness.
1
Thank you for this lucid and sensible advocacy for the mentally ill, who desperately need something better than prisons or homelessness to help them cope with their illnesses.
Shamefully, we have allowed care of the seriously mentally ill to deteriorate to the inhumane conditions that led to reforms known as "moral treatment" of the mentally ill in the 19th century.
Dorothea Dix was a leading 19th century figure in promoting better care of the mentally ill in the United States. We need someone with her vision and persuasive skills now!
48
I know he is an unpopular figure, but one person who has actually tried to do something about it, in the UK at least, is Prince Charles. His income is largely dedicated to the Prince's Trust, intended to get young people on the path to being self-supporting by both skills training, education, and mental health support.
Google the Prince's Trust for further information.
3
Now the mental hospital that bears Dix's name has been shut down in Raleigh in order to use the extensive campus for a city park. North Carolina has a few institutions, but not nearly enough, for the people who could benefit from them. Of course, the private ones are decent places, but only for those who can afford them, and only for relatively short stays.
I worked with a state council for developmental disabilities that promoted the idea that everyone should live with family, in their own home, or at least in a small group home setting. The concept was, of course, an ideal, assuming that people with physical and mental disabilities needing 24/7 care would be able to receive the care they needed. But they frequently don't because their families are unable to or unwilling to make the necessary sacrifices; they have no families; there are insufficient community support services at all levels to meet their significant and changing needs. The state guardianship system is broken, and often the only place "criminally" disabled patients can receive proper medical care is in a prison setting--assuming they're residing in a well-managed, humanitarian institution (not likely).
And we liberals are mocked and vilified for our "tax and spend" policies. The "liberty and justice for all" that we pledge starting in kindergarten is expensive to achieve. But then, we're only pledging allegiance to the flag--a symbol--not to the country.
3
Given the lack of mental health facilities in even liberal, pro government funding states, it seems a move back to explicit funding of larger institutions of the mentally ill would be helpful. Few people want to do the difficult, ill-paid work in the community, and fewer people want to pay for it. Building more of a hub and spoke system with clear criteria for commitment and forcible medication standards would also help. Being disorganized with repeated failure to thrive and homelessness should be a criteria for obligatory mental health therapy.
Note that mental health therapy may also encompass addiction treatment, which can often be a subset of psychiatric and psychology practice.
13
In liberal states, freedom is key. They err on the side of freedom. I know that conservatives rail about how liberals are trying to control everything, but it isn't true.
I worked in a nursing home and when the new rules were passed about patient freedom, we were skeptical. We had been allowed to restrain patients that we deem dangerous to themselves and to others before then.
The new rules stated we couldn't restrain them any longer, they had the right to fall. The right to be possibly more dangerous to others.
Now it did work out better than we thought it would, but restraints still had to be used in some cases and it was more difficult and time consuming. Time is the keen concern, when a patient is suffering from hallucinations and rampaging down the hallways where other residents are.
Funding has been cut badly to facilities across the field of mental health and physical health. Health care workers are not paid well for what is a difficult physical and mental job. Thus you have the least educated working in a field where education is key.
I worked with many people who had at best a high school education. Wonderful people, but it takes years of education to become knowledgable. And many quit long before considering how difficult the job is. They are desperate for work with no understanding of what the work entails.
Health care is something we do for profit and the results show that only profits are important in taking care of people. Health care is not for the sick in US
16
This same process is now being played out in the intellectual/developmental disabilities arena. Under the guise of “deinstitutionalization”, in order to continue to receive Medicaid waiver funding, the laws will now require that larger facilities are to be closed and individuals living in them transitioned to the community, where, supposedly, small group homes, jobs, and all needed supports will await them. This is happening despite the great opposition of their families whose loved ones are living rich full lives in communities now being designated as “institutions.”
Anyone want to wager on how it will all play out? Just another supposedly money-saving campaign against the most vulnerable.
89
They closed two institutions here in Iowa. Promised local beds and support. Now nothing, broken promises, broken lives.
5
We should partner with our mental health professionals and find a solution. People shouldn't end up in jail or living on the streets and families shouldn't be turned away when they ask for help. There's such a stigma attached to mental illness but most can lead very productive lives if they just get the proper support.
22
A plan like this would have saved my mother. I begged the doctors to commit her--she was a paranoid schizophrenic. And she had a gun--a shotgun. She shot out the door to our coat closet because she thought a CIA agent was hiding in there. "Can't commit her unless she harms someone or tries to commit suicide." The closet didn't count, nor did buying curare and a dart gun so she could try and shoot the telephone repairmen who were also apparently CIA agents.
And then people wonder why we have horrific things like school shootings . . .
I remember reading a book about the de-institutionalization movement. Yes, on one level warehousing people is wrong, and conditions were often deplorable. I get that. But I also read that the de-institutionalizaton advocates were not really interested in what happened to these folks after they were released. My mother eventually wound up living on the streets where she was bashed into a coma one night.
The toll on the ill person is tremendous, and the toll on the family is even higher. As we've seen with some of these shooters, the first people they shoot are their parents before they go out and shoot others.
It's time the pendulum swung back towards the middle--families need help with violent mentally ill relatives! And there has to be a way to keep weapons out of their hands!
116
I don't know who told you that you have to wait until someone actually harms someone else or themselves before being committed, but as far as I'm aware that is not a requirement in any state. I don't know what kind of "doctors" you are referring to when you say this but it's hard to believe that any were psychiatrists who didn't know anything about the laws of commitment in their states..
1
Asylum conditions weren’t deplorable. They were EVIL! And most of their inmates had never been armed with anything. If your mom broke bad in the home she OWNED, your had and should have had just one option: leave her be. If she didn’t own that home, you had plenty of “least restrictive” means of discarding her: eviction, restraining orders, or just leaving. You should never have been allowed to cage her BEFORE she commits a crime. And the health care system is NOT supposed to help patient’s families. It’s supposed to help the patients themselves. Clearly, you’re focused FAR too much on yourself, and not at all on your mom or on your duty to follow the law. Deinstitutionalization had begun explicitly to protect society from people like you.
Sorry about your experience. I used to manage a community mental health clinic near SF, CA and frequently heard horror stories from families similar to what you described here.
We really need to make changes to commitment laws. I have seen acutely psychotic clients deny that they are a danger to self/others frequently, even when multiple therapists, psychiatrists, social workers, family members, etc. who know the person well understand that the person is in danger due to acute psychotic decompensation.
I have also seen homeless folks who are actually reasonably stable, on meds, sober for the time being, etc. purposely tell cops they are a danger to self/others when the weather is bad so that they can get admitted to the hospital for the purpose of getting food and shelter.
California has a law that allows family members to contact police and initiate a gun violence restraining order, (GVRO) where firearms can be removed from someone who is mentally unstable for a period of time. I don't understand why GVROs have not become federal law yet. Many Republicans and even the NRA support GVROs. I wish Democrats would put the assault weapons ban on back-burner and start with something that it realistic and achievable in regard to federal gun control legislation - GVROs.
1
My father was mentally ill back in the 60s and was hospitalized in the state mental health asylum. I was a teenager at the time and my mother and I visited him regularly. His hospitalization was not an ideal solution, but it was a far better one for him and for us than attempting to care for him at home. Today's situation of basically no mental health institutions is a joke. I personally know of two men who were both brilliant and mentally ill who died on the streets. Our governments' lack of funding and lack of care for the mentally ill is shameful. We and my father were better off.
231
I am willing to bet that nearly every family who have tried to support the seriously mentally ill at home would agree with you. My relative is homeless in the streets. When we try to have her stay with us, she gets restless and abusive after a couple weeks. For us, it means having someone in our house that sleeps, watches TV, and keeps drinking. With no hope that will change because she can refuse all therapeutic help.
19
As a student nurse in the '60's, I lived in a dormitory next to a huge psychiatric facility for 3 months. We interacted with the patients and learned a great deal from them about psychiatric illness. It was an eye-opening experience that I will never forget.
The patients were not abused. They were treated by most with respect and kindness. And while their actual contact with a psychiatrist was minimal, they were safe and they were fed; they had hygiene facilities available to them. Was everything perfect, absolutely not, just like in our medical surgical hospitals. But when I think of my patients there being put out on the streets (thank you Ronald Regan) it absolutely sickens me and makes me so ashamed of the country I call home.
For much of my childhood years, mentally ill persons were not living in the streets. A rarely spotted street person was called a beggar or a hobo. Since it's usually nice and warm in Southern California, we have "beggars" on thousands of street corners and intersections, not all are mentally ill, but most are. I have often seen individuals, clearly in a psychotic crisis, walking down the street, oblivious to the reality around them. Some are very young and should be hospitalized immediately. They are so vulnerable to injury, to rape, but these people mean nothing to most Americans. We just look away and don't think about them.
If ignoring these people who are so ill, isn't abuse, I don't know what is.
19
Many years ago I had a summer job working at a Massachusetts state hospital. Most of the patients were schizophrenic and, at the time, there were no effective treatments for this disease/disorder. The patients were doped up, left in a zombie state, and they shuffled around the grounds and hallways.
It was Reagan, not Kennedy, who closed down these warehouses with the false promise they would be replaced by community centers. The result was a spike in homelessness and all the concomitant problems it generated.
About 10 years ago I volunteered at a rehab facility for alcoholics and other drugs abusers.
In both settings I learned that there were people who couldn't cope with every day mundane tasks. People who had to leave these facilities either "got well" or repeatedly "relapsed". Some of the relapsers were later found dead behind dumpsters or committed crimes with hopes of being jailed where there were beds and three meals a day.
Institutions are necessary. The problem, of course, is sufficient money to provide healthy and dignified care. But I wonder - what would be these costs compared against jailing, robberies, the courts, run down neighborhoods held hostage to drug dealers......?
230
"The Full Cost Of Incarceration In The U.S. Is Over $1 Trillion, Study Finds" and that finding was in 2016. With the DoD sucking up $770 billion for this year -- surely the case can be made that we're investing in the wrong priorities in this country.
https://www.huffingtonpost.com/entry/mass-incarceration-cost_us_57d82d99...
17
There are also quite a large percentage of seriously mental ill folks living in assisted living facilities that take Medicaid payment. Sometimes this works out well, but it's often difficult to provide adequate follow up care and staff are often poorly trained in providing care to people with chronic mental illnesses.
10
Actually the move from institutions to the idea of community mental health centers began under Carter.
The difference was that he actually sought funding for these while Reagan did his best to cut whatever funding there was.
6
I watched as mental hospitals were shut down in the Reagan era under the pretext of "helping" the former patients. But it was hardly just Republicans perpetrating the scam — in Massachusetts Governor Dukakis emptied state hospitals while glibly announcing how much better off the patients would be to be "integrated" into society — though it was plainly all about the money.
A schizophrenic college friend who was evicted from a hospital in Texas showed up on my doorstep around this time (he was released on the condition that he would "leave Texas"). In Massachusetts he was at least able to get some counseling and drug benefits that allowed him to survive for a while, but he committed suicide within a year. The crass lies about "better caring for the mentally ill by integrating them into society" and the gruesome reality still make my blood boil.
96
It actually began in the 60s. Many people were saying mental illness was just something placed on those that did not conform,etc. Some even said there was no such thing. I've read quite a bit about this, it's so disheartening.
5
Many more die in psych wards. The drugs are toxic and deadly and make ppl worse. They block all thought, not just bad thought, turn ppl into vegetables. Side effects are torture.they drive ppl to suicude.homicide.They are cause of mass shootings. I was in them.
2
I spent two years, in the mid-70's, as a clinical resident at two different state hospitals in the Deep South.
I remember well residents for whom those institutions were a relatively new "home" and I remember equally well residents for whom those institutions had been "home" for two and three and four decades.
But, no matter how briefly or how long those buildings and grounds had been "home" to them, I remember how devastating the realization was to me---young, green and oh, so idealistic---that few of them were or ever would be capable of managing lives of their own beyond those buildings and grounds. Indeed, for most, that was the reason they were there. They didn't represent threats to the world beyond, but the world beyond represented real threats to them. I once wrote in my journal that the walls surrounding those institutions weren't meant to keep my patients in but to keep the world that was/seemed so scary to them out.
That these institutions were "warehouses" is beyond dispute. But one man's "warehouse" is another's sanctuary.
A few years later, they boarded up those sanctuaries, tore down those protective walls and told my old patients that they had to find, on their own, new "homes" and new lives. The cruelty of it was beyond imagining---they were to do what they had already proven themselves incapable of doing.
BTW, they were right per those walls: Inside them they were safe, outside them they had no defenses against a world that truly was crazy.
295
Asylum - a protected or safe place.
I visited a big old fashioned asylum before it was torn down. It had a bakery, a dairy, a kitchen garden. People who could not deal with the real world felt safe there. Now they are living on the streets because - no surprise - the ‘care in the community’ which was meant to replace the care in the asylum never materialised.
58
I agree that bringing back “asylums” is a bad idea. Goodness, some of the mental health facilities that we already do have are already underfunded.
Less than 3 years ago, the news media in my state of Florida reported that $100 million in budget cuts made to our state-funded psychiatric hospitals resulted in widespread abuse and neglect. The conditions reported in those hospitals were shocking and deplorable. (I’m sure that the media exposure of these conditions is what caused our politicians to decide to start putting some of the money back into these hospitals.)
I want to also note that although some of the patients in the community psychiatric hospitals and the long-term state psychiatric hospitals are violent and a danger to others, there’s other patients in both of these types of hospitals that have never been violent or a danger to others. I should know. Several years ago, I was one of these non-violent patients myself.
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Good points. Gov. Scott should be held to account.
8
As a paramedic working in Brooklyn one summer night some years ago, we were dispatched to a call, circa 3 a.m. by a man in Fort Greene, Brooklyn calling from a pay phone, stating he had trouble breathing. Speaking in full sentences without any obvious distress, our assessment moved towards his social history (homeless/shelter). I sensed in his affect a behavioral reason for the call. I explained I had a few questions I had to ask; “that the ER triage nurse would not be happy if I didn’t ask them”. I asked if he wanted to hurt himself (suicidal ideation). He denied. I asked if he wanted to hurt someone else. He paused, and then explained in detail how he was sitting on the stoop of a brownstone, watching a man park his car. His impulse (denying a command hallucination) was to kill him. He wanted help. He also was rational enough tell ‘911’ he had trouble breathing so the police would not respond. I explained we would get him help, that I knew many in the ER that we were taking him to and they would help him as well. Some weeks later,
also at night, an EMT crew asked for assistance with a hostile patient. Arriving first I immediately recognized him. His impulses were now at the crew that was ‘bothering him’. We took over care and returned him to the ER. Clearly his care plan did not meet the needs of the patient or the community. The turnstile spins, and we all suffer the consequences.
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The threshold of what lands one in a psychward varies so much based on county, local social workers- etc. I was told I was a "danger to myself" for getting caught riding on top of a car. I was then sent to a institution that was terrifying, and those inside- so many bright young people- were beaten, drugged, had no hope of getting out- and even the meds had a nightmarish effect- tardive dydkinisia- sometimes permantently disableing with torturous constant facial muscle contortions. With one adverse reaction, my own tongue was clenching in the back of my throat so I could not breath... For 40 nights I knew that an hour after taking meds would be a terrifying rollercoaster until I passed out. Was this experience therapuetic for someone that wasn't suicidal or dangerous to others but merely had hypomanic symptoms that are encouraged throughout media (partying, drug use, hyperactivity)? My respect for this country died when a judge told me "the hippie days are over" and I got sent to an asylum. I speak of this because I now fear for my life- if I will die while being administered drugs I know I react badly to- in a place where I cannot refuse "meds." It is a terrifying existence to realize that you are a second class citizen and the issues Kristoff brings up to not address the awful reality of the current "mental health community". A measured approach is not called for-end this horrible system and stop state santioned torture.
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Thank you. I believe you absolutely. I'd like to think this happened to you a long time ago, but I bet it didn't.
1
I am a long term owner of a fairly large facility for the mentally disabled. As a child many years ago I also had the opportunity to spend a lot of time in a large state institution that is now gone. I have had family in my own facility. The state system was far better. The problem is that institutions for the mentally disabled are soft targets for the press, lawyers, and politicians. Pictures are published of drooling adults and children, shuffling around aimlessly or just sitting for hours etc. and the audience recoils in horror. But the horror really is about the human condition and not the facility taking care of these people. Among many, one advantage of large state institutions is that the employees used to get good pay and benefits and pensions and they had limited working hours which leads to safer and better care when dealing with a very difficult set of patients. Since the disastrous closing of the large state institutions the private for profit sector has taken over, so many choose to live on the street and spend their SSI cash on things they prefer like drugs, alcohol and cigarettes. The people that make a lot of money are the unscrupulous operators and care for the mentally disabled is a business race to the bottom. In the industry now caretakers are paid at the fast food level which leads to patient abuse and neglect. The advantages of a state institution are many. Care of the mentally disabled should be a community responsibility.
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What are the disability issues of the people who live in your facility? You refer to people with mental disabilities but it isn't clear whether you provide support to people with developmental and intellectual disabilities or mental health problems.
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"But the horror really is about the human condition and not the facility taking care of these people. " - Well, I'll give you the benefit of the doubt that your facility is actually taking good care of people. It's not my experience.
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thank you for stating this clearly.
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I am a psychiatrist who has been in practice over 35 years and find the idea that more " mental institutions " would prevent mass shootings ludicrous. Has mass incarceration prevented crime?
Many of my identified patients over the years owned guns and when questioned about access would roll their eyes at me implying how clueless I was about easy access to weapons.
We already universally screen for hearing and visual impairment in school age children. Ask any grade school teacher if they can identify the children in their classrooms with emotional or impulse control difficulties.
The task of screening and implementing interventions early on, is often ignored by school systems due to lack of proper funding, therefore passing the buck to the community.
Identifying potentially violent people, starting in childhood, is critical so that proper interventions can be implemented. Many of the recent mass shootings were perpetrated by people with clear histories of social and behavioral difficulties that with proper screening could well have been identified and managed from childhood onwards.
Obviously we also need tightening of gun licensing and availability.
Improving mental health services across the board should be good policy, not just in response to mass shootings.
Dorothy Zachmann M.D.
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Think about all the efforts that are made and the level of respect given to individuals with developmental disabilities. They have schools and residences and many multi disciplinary professionals working to help them and keep them in the community. In most cases their disability is life long with a continual need for assistance and care. Then look at people with mental illness. They were discharged from institutions in the 1960's due, predominantly, to psychotropic medications. But their follow up and community support never materialized the way it was supposed to. And they never have escaped the stigma of the disease and the lack of community acceptance. They are less likely to be violent or commit suicide than the general population, yet they are labeled as violent and/or likely to hurt themselves. Have you ever considered that maybe, just maybe mentally ill people are homeless and not approachable because of their fear of what you will (and more importantly want to) do to them? Engagement with society for them results in being dragged off, given medications with terrible, sometimes permanent, side effects, and being locked up against their will. And, in many cases when they do lower their guard and accept treatment, they are required to show progress toward a housing and vocational goal or else they are rejected. Re- Institutionalization after 60 years is the best we can do? Time to re-open leper colonies for people with resistant infections, I guess.
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Smi are developmental disabilities too, just at a later stage of development
1
You make a good point. Many mentally ill people scare us. Hence, the cruelty of the treatment of the insane. Insanity can be helped best by people prepared to deal with it, but such help is extremely labor-intensive and therefore very expensive. A double whammy: a frightening disease that is extremely costly to treat.
1
Writing as someone who as committed to Norwich State Hospital in Conn. for the "crime" of being suicidal, and tied to a bed, many times, and forcibly injected with powerful drugs until I was nearly unconscious, I want to protest as loudly as I can against any thought to bring back large warehouses for the very poor and the very lost.
It is an illusion to say that "mental illness" is, for the most part, a real disease. In fact, it is learned helplessness and a result of trauma. We learn to be dysfunctional and with help, we learn to recover. Recovery was never in the mental illness industry's lexicon, and Norwich was hell.
Later, as a Vietnam Veteran, I was able to use the Vet Centers and get sensible talk therapy for my, to me, obvious PTSD, and start the recovery process. I later lived for 5 years in a Eugene Oregon homeless shelter, as I slowly recovered both from the traumatic home, Vietnam, and from the drugs and horror of being labeled as being "defective".
No, Psychiatry has no authentic reason to exist, go to www.madinamerica.com and read some of the research and the comments of psychiatric survivors.
Hugh Massengill, Eugene Oregon
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First of all, thank you for your service!
Secondly, NO veteran should EVER have to go to a homeless shelter. It's a shame that veterans are treated with such a lack of respect in this country.
Third, I fully agree with what you say about "mental illness". Calling it a disease means imagining that nothing is needed to lead a normal, happy life, whereas that's obviously wrong.
Science has already shown that we all have an Inner Critic and an Inner Nurturer voice inside our brains. In order to have a meaningful life, we need to learn how to develop crucial brain circuitry that allows us to fully train self-care skills, including taking care of our negative emotions and calming and soothing ourselves when we're going through a loss or disappointment or even much more difficult things such as a war.
Developing that Inner Nurturer voice, through very specific, proven techniques, isn't taught at school, and mostly absent in our media/culture (movies, TV etc.).
So either you're lucky and you're born in a family that already inherited these skills from their predecessors, and then you develop them without even taking notice - or you're not, and then year after year, the high levels of stress caused by the lack of proper brain networks create a chemical imbalance in the brain, which, of course, can become so bad that the only way to no longer suffer is to commit suicide.
Many psychiatric facilities completely ignore this, and as a consequence do MUCH more harm than good ...
5
Hard to believe that you recovered in Eugene a place where I found all medical care to be pretty much exactly as you describe Norwich.
Mr. Massengill, so sorry for your suffering. You survived and triumphed. I always agree with your comments on other topics, which have appeared sane, sensitive, and sensible. Best wishes.
4
I work in corrections. The hardest part of my job is seeing an inmate with a mental illness become stabilized with medications, therapy, a consistent environment, and regular meals. (The facility I work in has mental health workers and offers group therapy, AA, anger management, dual diagnosis groups) only to return to the facility shortly after "killing their number". It is most likely they were self medicating with street drugs, not able to find a support group, and not able to continue with therapy in their community. Are asylums the answer? Would Community Mental Health Centers be better? Some patients need the stability of a consistent daily schedule and for them an inpatient care model would be appropriate. Some patients can function with an out patient care. We need a mental health care system that is funded. Period. Prison is a very expensive place for treatment (if it's even available in a facility) If the inmates that returned had kidney failure that required dialysis they would be able to get treatment because dialysis is covered by Medicaid and widely available. Because kidney disease is not perceived as a character flaw that can be conquered by making better life choices.
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You're pointing to the very essence of what this is all about.
In the West, today we only have two options when it comes to dealing with people suffering from mood disorders that are so bad that they can't work or live on their own any more: either we call it a "disease", and then focus on prescription drugs (even though many of them don't work, and we often ignore why those that work do so, whereas long-term side effects are quite horrible), or we dismiss them as "character flaws" - supposing that it's that person's own fault and that a bit more "willpower" (combined with public shaming) should be enough to get rid of the problem.
As your comment shows, however, in real life these people do need help, as they've never been taught basic self-care skills. And to develop those skills, a very complex and specific social environment is needed:
- a consistent daily schedule
- regular meals
- support groups
- activities that allow them to increase emotion management, self-esteem, and overall well-being and happiness (what Julie Simon calls strengthening your "inner Nurturer voice", through specific emotional self-care techniques)
- access to competent mental health workers and if necessary/unavoidable (for instance during an acute hallucination crisis) psychotropes.
In this regard, it's not comparable to any other disease - and certainly not a "character flaw" either, as those are highly trainable skills, people just need to meet other people who can teach them ...
13
Thank you - such a valid comment from someone who is on the front lines.
3
A close friend was in crisis. They were aware enough and unfortunately experienced enough to know even though they were suicidal saying that would not get them admitted. I had previously thought slitting your wrists was a cry for help. Now I know it to be a reasonable action to get access to care.
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I believe that. In addition to committing people involuntarily who probably don't need it, being in the middle of a psychotic break is sometimes not enough to get admitted. Our loved one attempted to sign in to a facility and was turned away because they said they weren't thinking of harming themselves or anyone else. So, too bad so sad, you'll have to just go on in your delusional state, untethered from reality, we can't help. We hear you are crying out for help but we've got nothing. The irony was, it was truer than we knew - they had nothing. At that point, we didn't yet understand that once our loved one was admitted, nothing was going to be done for them anyway, other than being drugged into zombiehood, and ignored 23 hours out of 24. (The remaining hour being "group therapy," which consisted of going around the room reporting whether or not you were hearing voices today.)
3
Our smart, well-spoken son suffered several traumatic brain injuries n his twenties which have left him, at age 31 with severe seizures, which in turn have permanently fogged his brain. Doctors have advised him the seizures will get worse as he ages. He receives $900 a month in disability and has Medicare insurance. But there is no coverage for long term mental health care and even if there were, as the author of this story said, the services don't exist. We do not have the resources to care for him. After ending up in the ER in Charleston, SC, they transferred him in-patient at a psychiatric facility there twice. Ultimately, with no other options, they put him on a bus to a homeless shelter in Wilmington, NC where he is now. There, he's already been in the ER twice. He needs and wants to be institutionalized. Instead, he'll be homeless. Ifhe lived in a European country, he wouldn't be facing this choice. What have we become?
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I am sorry to be the one to tell you that we have not "become" this we have always been this. We are a classed society not very much different from a feudal society where propaganda about freedom and choice are used to hide the fact that the upper classes have managed to steal our government by the people from us right under our noses with the full support of many of our fellow citizens and used its authority to impose a feudal system on us and use "double speak" on us to convince many that this is what the founders intended.
15
My brother in law has schizophrenia and went off his medication 4 years ago. He has threatened both myself and his mother. He threatened to kill me to my face 3 times. while he was on a psych hold he also told the doctor that he wanted to kill me. That was not enough for them to hold him. Not only that, but they let him out, and only after letting him out, told me I needed to get a restraining order. Well that process is much easier to do when you know where the person is! Ultimately I did get the restraining order, and my brother in law is still off the meds. He desperately needs help, but doesn't know it. and his family has no way to help him because of how these laws work. It is a mess. The system is beyond broken.
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Take it up with the ACLU and the other advocates of personal liberty who fought to tighten laws against committing people to mental institutions and then did nothing about funding for outpatient care saying that that wasn't a problem they dealt with. Rarely in the history of the U.S. has any group of people been so responsible for so much misery.
8
My mother was given a lobotomy by Walter Freeman, the man who also lobotomied Rosemary Kennedy. It was only after the lobotomy that she ended up being institutionalized and it was therein a mental institution in the cornfields of Iowa, run according to the Kirkbride strictures, that she found the care and compassion that allowed her to leave and lead a productive life. There is a lesson to be learned from her experience.
18
Something about the US shrinks prefrontal lobes without surgical intervention.
3
I can't believe a comment essentially advocating lobotomy for a loved one is a "Times Pick." This is where we've come as a society in the all-out war on mental illness and the collateral damage of human beings in the process.
4
Does a lobotomy result in a passive individual, bereft of all sense of agency?
1
Arguing against asylums is easy, given the historical horror shows of inept management, terrible state supervision and murky interface with the legal system that most of them were. But you have to be careful of the fallacy of the mutually exclusive extremes. While the old asylums were generally very bad, that does not mean that some people are so disordered, dangerous and refractory to treatment that they shouldn't be kept in a safe place for a long time. After Geraldo Rivera gave us video from the Willowbrook State School, RFK and other pols got involved with good intentions but spotty outcomes. The ultimate result was closing the big institutions, relying more heavily on community mental health centers and the drugs they prescribe and more seriously mentally ill in jails and prisons. This is a huge complex issue that deserves real study by people who understand it. Let's try and do something good with it before those of us who remember Willowbrook and similar places are all passed on.
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