This is really more a reminder to myself to have something ready to post on Friday. Still, I thought I’d give you all a heads up. More details about this can be found at Diary of a Goldfish.
Now that the day is here, I have something to post! This is a comment on the Inside Higher Ed article,”One Year Later,” on the Virginia Tech shootings. The article itself was okay, although as usual the discussion centered around gun laws, not the rights of mentally ill persons to adequate treatment. The disabilism was very apparent in the comments though. The first comment, from Clayton Cramer, concluded
“Deinstitutionalization was one of the major mistakes of the 1960s and 1970s. The mentally ill are paying the price for it today, and so is the rest of our society.”
Of course, this fellow opposes gun control (and supports home schooling, and criticizes affirmative action. citizens of Idaho — do not vote for him!) So, his solution is to lock all the “crazies” away — oh wait, we’re already doing that at least according to what my colleagues in criminal justice say about the high rates of mentally ill persons in prison.
Rod Bell, Adjunct Professor at College of DuPage, said something similar, blaming this all on the hippies in the sixties who revolted against authority. Sheesh, I hope this guy isn’t an adjunct professor of history. This is just a sloppy historical analysis that would get an “F” in any of my classes. For the record, dude, it was John F. Kennedy, not the hippies, who initiated the move away from warehousing the mentally ill in asylums in favor of community-centered mental health. Also, exposes of the hideous conditions inside psychiatric hospitals were made by WWII conscientious objectors, i.e. long before Ken Kesey’s novel.
Added later: In reply to Mr. Cramer’s comments, I would say first that my point is that it is indeed simplistic to attribute the current mental health crisis solely to the anti-psychiatry movement and/or the anti-authoritarian impulses of the 1960s (whatever is meant by that — a subject for another post). As Gerald Grob and Howard H. Goldman observe in their recent book, The Dilemma of Federal Mental Health Policy, the move from mental hospitals to a community-based system of mental health care delivery was the product of a broad coalition of mental health experts, patients and their advocates, and politicians such as President Kennedy among many others. The complexity of this movement, I think, gets lost because of the fame of Ken Kesey’s book and the academy-award winning film that was made from it, as well as the notoriety of Thomas Szasz’s work (for the record, I have multiple problems with Szasz, but that too is a subject for another post).
The reason the Community Mental Health programs initiated in the 1960s failed is not because they emptied the hospitals, but because there was never enough funding to meet the need for services. We have millions of uninsured individuals in this country, and many insurance plans do not offer mental health parity. Although the state of Connecticut mandates this for all health plans, the new Charter Oak Health plan proposed by our Governor to cover uninsured adults excludes mental health parity because it is too costly. A bill (HB 5617) has been proposed to solve this problem.
I could go on and on, but I do have to get ready for class, where we will look at all those crazy feminists who messed things up for the rest of America by asking for the radical notion that women be treated like human beings.
Knitting Clio 
You are mischaracterizing my position. What we are currently doing is waiting until the severely mentally ill commit a very serious crime–and then we send them to prison. This is bad for the mentally ill and bad for their victims. It is also bad for the taxpayers, since it is considerably cheaper to provide mental health services, either outpatient or inpatient, before someone gets bad enough off that they end killing someone or close to it.
“For the record, dude, it was John F. Kennedy, not the hippies, who initiated the move away from warehousing the mentally ill in asylums in favor of community-centered mental health. Also, exposes of the hideous conditions inside psychiatric hospitals were made by WWII conscientious objectors, i.e. long before Ken Kesey’s novel.”
Speaking of sloppy historical analysis, the first claim is accurate but woefully incomplete. The Community Mental Health Centers Act of 1963 indeed played a major role in emptying public mental hospitals (to the benefit of some mentally ill patients, to the detriment of many others), but the antiauthoritatarian sentiments of the 1960s (which were shared by a lot more than hippies) also played a role in the development of the antipsychiatric movement.
Conscientious objectors played a major role in exposing deplorable conditions in many mental hospitals, which had suffered severe funding shortages during the Depression and World War II. But at least they were reporting about real problems–not Ken Kesey’s LSD-driven novel.
The real history of deinstitutionalization is a bit more complicated than this simplistic view that you are spouting.
Thanks for clarifying your position. How do you propose to identify and treat mentally ill persons? Isn’t outpatient treatment a lot more cost effective (not to mention humane) than long-term hospitalization?
We actually have a pretty good system for identifying those with serious mental illness problems right now. Part of deinstitutionalization was not just emptying out the mental hospitals (“opening the back door of the asylum” in the terminology of the time) but “closing the front door” by adopting extraordinarily strict standards for commitment. I will agree that some states had excessively informal procedures, such as led to the Lessard v. Schmidt decision, but I have been hunting for a long time for evidence that there was widespread abuse of these processes. I can find isolated examples, but as late as 1963, the ACLU’s representative to Congressional hearings about D.C.’s mental health system could not point to any examples of inappropriate commitments there. I find it hard to believe that she whould have neglected to point to such abuses elsewhere.
Some states went so far off the deep end on this that psychotics were starving themselves to death–while family and police looked on helplessly. The Portland Oregonian had a long series about six years ago about many such examples that they could find, caused by the courts using a very demanding standard for what constituted “imminent danger.”
Outpatient treatment is definitely cheaper and preferable. One of the issues that I am raising in my state senate campaign is that about five years ago, the Idaho Dept. of Health & Welfare decided to “save money” by taking a very strict view of the Medicaid reimbursement requirements. As a result, there is no Medicaid reimbursement for outpatient mental health services in most of Idaho today. And Medicaid mental health expsnses rose from a bit more than $50 milion in 2003 to about $115 million in 2007. Patients who don’t get treatment outpatient may end up inpatient after a suicide attempt or a violent attack on others–and that’s $1000 a day. Sometimes, saving money doesn’t save money.
Outpatient treatment is the best choice. But there are times that it just isn’t possible. Many psychotics reach a point where they are utterly convinced that they are sane, and the rest of the world is crazy. Some respond well to temporary treatment options (if the laws of the state allow this without the patient having done some horrifying crime first), and can be then released back to community treatment. Some do not. Some end up in and out of temporary treatment repeatedly, and may actually be better off committed. Of course, once they start killing people (as happens with depressing regularity), the option of community treatment is off the table.
You can see some of my work in process for my seventh book by looking at http://www.claytoncramer.com/weblog/labels/deinstitutionalization.html — a series of news items, ruminations, and interesting stuff that I found while researching the subject.
“The reason the Community Mental Health programs initiated in the 1960s failed is not because they emptied the hospitals, but because there was never enough funding to meet the need for services.”
This is a highly arguable point. There are certainly people who were not, and are not insured. But under the parens patriae view of the state’s role, the government provided mental health services on an inpatient basis. If the community treatment approach was flawed for this reason, it was also flawed in a number of other ways as well. At least in the public mental hospitals, patients had a roof over their heads, and little risk of freezing to death. Hypothermia death rates more than doubled in the U.S. from 1974 to 1984. Does anyone seriously doubt that there was a connection to deinstitutionalization?
In addition, lack of coverage isn’t the major obstacle for many of the mentally ill wandering our streets. They are eligible for Medicaid, and many actually receive it. But those who are severely mentally ill often see no reason to get help–and vigorously resist it when offered.
In addition, community mental centers set up by the federal government under the Community Mental Health Centers Act started to lose sight of their original function. By the 1970s, many had become more interested in neurotic housewives and drug abuse treatment than in the scary psychotics–to the point where families of psychotics were complaining that they were being put in separate waiting rooms. Some of the CMHCs also got lost in radical racial identity politics as well–and ceased to be terribly effective.
“where we will look at all those crazy feminists who messed things up for the rest of America by asking for the radical notion that women be treated like human beings.”
I do hope that your teaching is more serious and thoughtful than your remarks here.
Mr. Cramer, you are promoting a lot of myths and propaganda in your comments here. When institutionalization was in full swing, half the folks in state hospitals were women. Half the folks on the street and in jail now are not women–it is not the same people so your connecting the two is confusing correlation with cause and effect.
It is also offensive to continually refer to citizens of your state as “psychotics” rather than as people with a disability or people with mental illness. No one is psychotic all the time for one, but for two it’s dehumanizing and may explain your outdated attitudes which reflect prejudice and disdain.
You promote the slander that people with mental illness are likely to kill people without treatment, this is simply a lie. People with mental illness are no more violent than people without and in fact are far more likely to be victims of crime than perpetrators of crime.
The ACLU has never taken seriously the civil rights of folks with psychiatric disabilities in institutions and doesn’t to the present day so acting as if their lack of advocacy reflects the true state of affairs in mental hospitals is ridiculous.
Whether Ken Kesey was on drugs or not when he wrote his book has no relevance to the truth of his novel. Then and now people in state hospitals are forced to undergo ECT against their will, abused by staff, killed on a regular and disturbing basis by unneccessary prone restraints and other forced interventions in the hospital, treated like prisoners in a prison and generally degraded and put at risk for sexual assualt and trauma.
The increase in homelessness in this country can be directly tied to the cut backs in the social contract/saftey net that started under Ronald Reagan and continue to this day and to the lack of investment in affordable housing.
Mi
The whole lack of insight canard manufactured by the Treatment Advocacy Center and NAMI and promoted by people such as yourself is a straw man meant to distract from the fact that community services work when offered in a voluntary and user friendly manner and without long waiting lists and bureaucratic barriers to access. If other health services were run in as patient unfriendly manner as mental health services are, there would be an outcry, but because of the prejudice against people with mental illness, demeaning attitudes,long waits, and poor quality of services are accepted as the standard of care. Glad you aren’t running for office in my state.
Let’s see: something else that changed was that Medicare meant that there was a large movement of elderly senile from public mental hospitals to private nursing care. From 6% to 15% of the mental hospital population into the 1940s was syphilitic insane–which has become extraordinarily rare because of the widespread use of antibiotics. That alone explains significant demographic changes.
Another important factor that you are missing is because mentally ill women are less violent and less scary than mentally ill men, they often manage to find a place to live where men who are just as mentally ill do not.
Substance abuse is a cause of mental illness, one that has become more common over the last several decades. Men have higher rates of substance abuse than women; no surprise that they tend to be more common among the mentally ill and among the homeless.
1. Psychotic is an accurate description of person’s whose illness is so severe that they have lost touch with reality.
2. You are incorrect when you say “No one is psychotic all the time.” There are people who are indeed psychotic all the time. Some may be asymptomatic at times, or in response to the use of antipsychotic medicines, but your statement is strong on Political Correctness, weak on actual fact.
3. My attitudes do not reflect “prejudice or disdain.” They reflect that I have an older brother who has been schizophrenic since 1973, and I have spent much of the last two years researching the subject.
2 whole years, my goodness. I started studying psychology in 1980. Asymptomatic means not psychotic. Or are we going to argue about the meaning of “is” here, if so, I don’t have the time. Hey, if you don’t mind being offensive, go for it. Being offensive is all the rage these days, it’s what all the cool kids are into. If PC means possibly compassionate, I confess I am. I do care about the feelings of folks who are the most maligned in our society. But I don’t think that is politically correct, quite the opposite, what’s politically correct these days is not to give a darn about the effects of one’s words on disenfranchised groups. We are “tough on crime” even if it means locking up innocents. We have “zero tolerance” even if it means kids lose their opportunity to have an education and to have a second chance because they are children. We laugh at rape of men in prison. No I’m not PC, PC today is to say whatever comes to mind and never give a thought to who might be hurt. What I am is a dinosaur.
It seems to me the two of your are talking past each other, so I’m going to ask the two of you to take your exchange to your respective blogs.
To sum up the discussion as I see it.Diary of a Goldfish has a post on the Language of Disability that is relevant here: http://blobolobolob.blogspot.com/2008/04/language-of-disability.html
The problem here is using “psychotic” as a noun so that a person is identified soley with his or her disability, rather than saying someone is a psychotic person, which acknowledges a person’s common humanity. I would liken it to using the term “retard” to refer to a person with a developmental disability. As I state in a forthcoming article in _Harvard Review of Psychiatry_, we need to avoid playing into persistent cultural myths about individuals with mental illness, which portray these individuals as more prone to violence and qualitatively different from “normal” people. In our zeal to protect the campus from mentally diseased “others” we run the risk of will duplicating the kind of profiling of Arab Americans that occurred following 9/11.
My flippant comments about feminism are relevant as well (by the way, my students appreciate a sense of humor) — the feminist movement asked that women be treated as human beings not as sex objects or second class citizens. The same is true of civil rights activism, and other social movements.
Although some marginalized groups have reclaimed derogatory language for their own purposes (e.g. Chris Rock and the N-word, “Queer Eye”) this does not mean others can use them with impunity.