The age of deinstitutionalized mental health began in the 1960’s with the advent of medicine that helped to control the symptoms experienced by the afflicted and institutionalized. It was liberating. The collective conscience of the day believed that by releasing the mentally ill we would reintegrate into society the thousands of people and bring them back into our liberal family. The legion of state hospital beds were no longer to be needed. Or so we were told.
On the one hand, there were many who embraced the idea of deinstitutionalizing thousands of patients. They were to be promised catchment area clinics where they could see their doctors and receive on-going care. Many thrived in community-based programs but there were just as many who where frightened by the sudden loss of structure and routine afforded them by the state hospital system that had become their homes. For many they had nowhere to go. There was nothing for them in the communities across the country and no welcome mat to offer comfort.
“In Massachusetts, as elsewhere in the United States, the closing of state psychiatric hospital has been a highly contentious issue” (Ahmed & Plog, 1976; Morrissey, 1989).
It is well known that the state hospital system across the country was not sustainable. Here in Massachusetts, there were more psychiatric beds than there were medical beds. As the pharmacology of mental illness became better understood there was less need to keep people with severe mental illness in hospitals. Treatment options became community-based including access to a broad range of therapy now available for management of symptoms of mental illness.
“In Massachusetts, as elsewhere in the United States, the closing of state psychiatric hospital has been a highly contentious issue” (Ahmed & Plog, 1976; Morrissey, 1989). Yet, then Governor William Weld had closed the majority of state hospitals by 1993.
Thus, the closure of hospitals began in earnest, in the late 1980’s, so patients could be released to communities everywhere to live their lives in the least restrictive environment needed assured of their right to treatment and the right of free choice. The problem was that many of the institutionalized were unprepared for the world that awaited them. They were afraid to take the medications being pushed on them and refused to comply. Many had no welcoming family and many had no friends. Some slowly evaporated into a cold society who were unkind to people who were strange and muttered to themselves.
Money spent keeping thousands people Americans in state hospitals could now be funneled into community clinics and those with mental illness could return to their homes. The ground swell for this model resulted in hundreds of thousands of institutionalized human beings being released to alternative programming that, for some, was both disruptive and tortuous or never materialized. The promise of “cures from mental illness” was laid at the feet of the purveyors of psychotropic medication and the pharmaceutical companies across the country. There was money to be made by opening the doors of the state hospitals in community-based programs like the Los Angeles County Mental Health in Long Beach, CA – my first assignment as a psychologist.
So now we are at ground zero in terms of programming for the 2-3 percent of individuals with major mental illness like schizophrenia, bipolar disorder, paranoia, major depressive disorder, and others. They wander the streets moving in and out of shelters. They are a herd in some cities and are driven from one side of the street to the other. And back again, as political whims dictate. They frequently come into contact with law enforcement who may not wish to go “hands-on” with someone who is hallucinating and raving about his demons.
In 2020, CIT teams are trained in de-escalating the crazed for their own safety while a co-response model brings a licensed mental health worker to the scene to call for a bed or lend a supportive ear. Many are repeat encounters or “frequent flyers” as they are known. Sadly, the access to hospital beds is a closely guarded secret and there is often no place to send them. The personnel serving the mentally ill make call after call looking for someplace to admit the person now on their radar screen. This can take hours. It is tough work, I have done it, and took pride in the cases I was able to help. But the burn out rate is very high and jobs are always available.
Stabilization and hospitalization of people in crisis is a moral responsibility of us all. Without resources there is a large part of our society for whom there is no safety net suffering with emotional illness that often leaves them marginalized, despondent, and on the brink. And no one is better off with a system that is as impoverished as this. The pendulum should slowly swing back toward a new model that may accommodate the seriously mentally ill while bringing stabilization to those who require respite from the scary place in which they live filled with demons, too often in their heads.