Deinstitutionalization Still Haunts Us Sixty Years Later

Deinstitutionalization, the name given to the policy of moving people with serious brain disorders out of large state institutions and then permanently closing most or all of those institutions has been a major contributing factor to increased homelessness, incarceration and acts of violence in this country. It is also a fundamental component to the current mental illness crisis, and unfortunately no end is in sight for this crisis.

Deinstitutionalization was based on the principle that severe mental illness should be treated in the least restrictive setting. While this was a laudable goal, the consequences have been catastrophic. The current "least restrictive setting" is often a cardboard box, a jail cell, or worse.

Nearly 8 million Americans suffer from a serious mental illness that grossly impairs their thought processes, such as schizophrenia or bipolar disorder. Treatment in most cases can control psychiatric symptoms common to these diseases, but the system that once delivered psychiatric care for them has been systematically dismantled over the last half-century. Today, half the population with these diseases is not taking medication or receiving other care on any given day.

Timeline of Deinstitutionalization:

1773: The first patient is admitted to the “Public Hospital for Persons of Insane and Disordered Minds” in Williamsburg, Virginia.

1841: Boston schoolteacher, Dorothea Dix, visits the East Cambridge Jail, where she first sees the horrible living conditions of the mentally ill. Believing they could be cured, Dix lobbies lawmakers and courts for better treatment until her death in 1887. Her efforts lead to the establishment of 110 psychiatric hospitals by 1880.
1887: On assignment for New York World, Nellie Bly feigns lunacy in order to be admitted to the Women's Lunatic Asylum on New York’s Blackwell's Island. Her exposé, "Ten Days in a Mad-house,” detailing the appalling living conditions at the asylum, leads to a grand jury investigation and needed reforms at the institution.
1907: Indiana is the first of more than 30 states to enact a compulsory sterilization law, allowing the state to "prevent procreation of confirmed criminals, idiots, imbeciles and rapists." By 1940, 18,552 mentally ill people are surgically sterilized.
1936: Dr. Walter Freeman performs the first prefrontal lobotomy. By the late 1950s, an estimated 50,000 lobotomies are performed in the United States.
1938: Italian neurologist, Ugo Cerletti, introduces electroshock therapy as a treatment for people with schizophrenia and other chronic mental illnesses.
1946: President Harry Truman signs the National Mental Health Act, calling for the establishment of the National Institute of Mental Health to conduct research into neuropsychiatric problems.
1954: Chlorpromazine (aka - Thorazine) is the first antipsychotic drug approved by the Food and Drug Administration; it quickly becomes a staple in asylums.
1955: The number of mentally ill people in public psychiatric hospitals peaks at 560,000. The widespread effective use of Thorazine sets the stage for moving patients out of hospital settings. Deinstitutionalization officially commenced.
1962: One Flew Over the Cuckoo's Nest, a novel by Ken Kesey, is published. The bestseller is based on his experience working as a nurse's aide in the psychiatric wing of Menlo Park Veteran's Hospital in California and highlighted problems with institutionalization.
1963: President John F. Kennedy signs the Community Mental Health Act to provide federal funding for the construction of community-based preventive care and treatment facilities. Between the Vietnam War and an economic crisis, the program was never adequately funded.
1965: With the passage of Medicaid, states are incentivized to move patients out of state mental hospitals and into nursing homes and general hospitals because the program does not pay for individuals in "institutions for mental diseases."
1967: The California Legislature passes the Lanterman-Petris-Short Act, which makes involuntary hospitalization of mentally ill people vastly more difficult. One year after the law goes into effect, the number of mentally ill people in the criminal-justice system doubles.
1977: There are 650 community health facilities serving 1.9 million mentally ill patients a year.
1980: President Jimmy Carter signs the Mental Health Systems Act, which aims to restructure the community mental-health-center program and improve services for people with chronic mental illness.
1981: Under President Ronald Reagan, the Omnibus Budget Reconciliation Act repeals Carter's community health legislation and establishes block grants for the states, ending the federal government's role in providing services to the mentally ill. Federal mental-health spending decreases by 30%
1984: An estimated one-third of all homeless people are considered seriously mentally ill, the vast majority of them suffering from schizophrenia.
1985: Federal funding drops to 11% of community mental-health agency budgets.
1990: Clozapine, the first "atypical" antipsychotic drug to be developed, is approved by the FDA as a treatment for schizophrenia.
2004: Studies suggest approximately 16% of prison and jail inmates are seriously mentally ill, roughly 320,000 people. This year, there are about 100,000 psychiatric beds in public and private hospitals. That means there are more than three times as many seriously mentally ill people in jails and prisons than in hospitals.
2009: In the aftermath of the Great Recession, states are forced to cut $5 billion in public mental-health spending over the next three years, the largest reduction in funding since deinstitutionalization. States cut $5 billion in mental health services from 2009 to 2012. In the same period, the country eliminated at least 4,500 public psychiatric hospital beds
2010: There are 43,000 psychiatric beds in the United States, or about 14 beds per 100,000 people—the same ratio as in 1850. (Source: Mother Jones)

Effects On Law Enforcement:

From police departments to courthouses to jails/prisons, the care of those who are mentally ill currently weighs heaviest on law enforcement authorities. Quite simply, this is not only unfair to the police (who are not mental health professionals) and to individuals who are in need of treatment, it is also rather barbaric. Can you imagine what would happen if law enforcement was the first line responder with medical conditions, diagnoses, or emergencies?

At a time of heightened concern over police shootings, a new report by the Treatment Advocacy Center estimates that people with mental illness are 16 times more likely than others to be killed by police. The research study reported that people with severe mental illness account for one in four of all fatal police encounters. LAPD reported that more than a third of the people shot by Los Angeles police in 2015 had documented signs of mental illness; this represented nearly triple the number of such shootings from 2014.

On the other side of the coin; encounters by police and corrections officers with a mentally ill individual can quickly turn dangerous or even deadly. Most veteran officers will agree the most volatile situations they have encountered have been with the severely mentally or emotionally impaired. People in the grip of psychosis often behave unpredictably and sometimes violently. For example, people who suffer from severe mental illness often panic, fight, or attempt to flee when confronted by police. Individuals who suffer with auditory hallucinations may not understand a police officer's commands to stop, drop a weapon or put their hands up. Of the 127 officers who lost their lives in the line of duty in 2014, six (15%) were killed by mentally ill suspects. Statistics confirm that individuals with severe untreated mental illness are in fact violent. While only 1.5% of the population has a severe untreated mental illness, approximately 10% of homicides committed each year are by those who had a severe untreated mental illness; additionally, approximately 50% of mass killings have been committed by individuals with untreated severe mental illness.

This problem becomes even more complicated when intervention is imminent. Many times the seriously mentally ill are unable to get treatment until their violent behavior attracts the attention of the police. Additionally, there is a very serious lack of mental health facilities for which to take these individuals. The step of finding treatment for the mentally ill before arrest and incarceration was eliminated by the deinstitutionalization of the mentally ill and the subsequent failure to provide comprehensive outpatient treatment. Driving a mentally ill individual for hours to get treatment can drain a department’s resources for other public safety calls. Finally, there is a persistent lack of police law enforcement training on how to effectively de-escalate any potentially violent situation involving a mentally ill subject.

Can Anything Help Correct These Problems?

The Treatment Advocacy Center offers the following suggestions:

Shifting the responsibility for responding to acutely ill individuals from mental health professionals to police has criminalized mental illness at enormous cost to individuals with the most severe psychiatric diseases, the criminal justice system and society. The mental illness treatment system must be restored sufficiently so those with mental illnesses receive treatment before their actions provoke a police response.

Lawmakers need to enact and implement five public policies to achieve these goals:

Increase the number of treatment beds for individuals suffering from acute or chronic psychiatric conditions. The number of public psychiatric beds in America has plunged more than 90% since the 1950s while the U.S. population has nearly doubled. Today, it is well established that roughly 20% of all inmates have a serious psychiatric disease, but individual facilities report that up to 50% of the prisoners in their facilities have a mental illness.
Reform treatment laws that erect barriers to treatment for at-risk individuals, including laws that require courts to wait until individuals become violent, suicidal or gravely ill before intervention becomes possible.
Make full use of laws that provide access to treatment for individuals too ill to seek treatment for themselves.
Expand the use of court-ordered outpatient treatment (assisted outpatient treatment or AOT), and other evidence-based practices that demonstrably reduce the likelihood of individuals with severe mental illness becoming police calls. AOT authorizes court-ordered mental health treatment, including medication, for individuals with severe mental illness who, because of their inability to stay in treatment voluntarily, have a history of poor outcomes (e.g., repeated hospitalization, incarceration, suicide attempts). AOT has been deemed an evidence-based practice for reducing crime and violence in the U.S.
Make treatment funding decisions that consider both the cost of treatment and taxpayer savings that result from providing treatment that reduces criminal justice involvement, homelessness and emergency medical services and other public costs.

The establishment of Crisis Intervention Teams (CIT), which is the collaboration of police and mental health service providers, has proven effective in appropriately serving the needs of individuals experiencing mental health crises who come to the attention of law enforcement agencies. These teams are able to evaluate a mentally ill individual, identify their needs, link them to appropriate services, and divert them from the criminal justice system if appropriate.

If you are in an urban setting, by the time you finished this article there has probably been a dispatch call related to a mentally ill individual. Rural officers often know them by name. If you are really curious about how many untreated severely mentally or emotionally individuals live in your state, click here.

http://www.treatmentadvocacycenter.org/storage/documents/Research/sz%20and%20bp%20numbers%20by%20state.pdf

Stay safe out there.