Homeless shelters are the new mental health facilities

Roughly 150,000 to 200,000 individuals with schizophrenia or bipolar disorder are homeless. In the absence of psychiatric hospitals, homeless shelters are yet another example - along with jails and prisons- of today’s “mental hospitals”.

Out on the streets, people with mental illness and addiction problems are guaranteed neither a home, food, health nor safety.

As [Dennis] Marble [executive director of the Bangor Area Homeless Shelter] and many others see it, the morphing of the homeless shelter into what Marble calls an "underfunded mental health facility" is one of the unintended consequences of the "downsizing" of the state’s mental health institutions, including Bangor Mental Health Institute, now known as the Dorothea Dix Psychiatric Center.

A major complaint of the critics of deinstitutionalization was that adequate community resources were not put into place to support patients after their release. As a result, many did and still do wind up in homeless shelters or jails, which are increasingly hard-pressed to house them adequately.

"I look at some of the folks who come here and it’s pure and simple — they can’t [fend for themselves]," Marble said. "And for me to say the right thing for them is to live their lives in this shelter and that’s their choice? That ends up ringing hollow really fast."

Re-institutionalization?

In the waves of deinstitutionalization of the 1950s and 1960s the number of people with severe mental illnesses in public inpatient psychiatric facilities dropped dramatically.

In 1955, 558,239 patients were in public psychiatric hospitals. By the
mid-1990s, the number had dropped to fewer than 72,000. By 2002, the total had fallen below 50,000.

Where did they all go? Too many ended up on our streets, in homeless shelters, in emergency rooms, and in jails and prisons.

In Colorado, the director of the department of corrections is requesting nearly $60 million to double the size of a 250- bed correctional facility to house mentally ill inmates.

Colorado isn’t alone. In Maine, Governor John Baldacci announced a plan to have the state assume control of all 15 county jails. Some jails, according to the plan, will be turned into “specialty facilities for people with mental illness.”

Almost 50 years after the first push for deinstitutionalization it seems we’re still housing people with severe mental illnesses in institutions. Now we require them to commit crimes to get there.

Advocating from an ivory tower

We always assumed that Michael Allen and his cronies at the Bazelon Center (Michael is a former employee) were just ignorant of the science behind the need for commitment laws, or perhaps too busy to actually READ the statutes on outpatient commitment and thus assumed the worst. They certainly are eager to shut down the nation’s psychiatric hospitals, so one would think they would be strong proponents of outpatient commitment – a way to get people help in the community.

Is it possible that they have been in that ivory tower for so long they don’t actually know what life is like behind bars if you have a mental illness?

How else can you explain Michael Allen’s bizarre comment on NPR that he doesn’t know if it is worse for a person with a severe mental illness to be in a psychiatric hospital or in prison.

We wish someone would push Bazelon and their ilk to offer some real solutions – it seems now that they are opposed to psychiatric hospitals, mental health courts, and outpatient commitment. So perhaps they have no choice but to downplay the victimization and brutality that face people with mental illnesses who are locked up. After all, if Michael Allen has his way, looks like that is where more and more of them will be ending up.

Few options left

An op-ed in The Day in New London, Connecticut had the following to say about deinstitutionalization:

At the threshold of the 21st century, a disturbing trend has become evident. As the number of hospitalized adults decreased during the second half of the 20th century, the number of prison inmates with serious mental illness was on the rise. In fact, the federal Bureau of Justice Statistics (BJS) reports that the number of inmates in jails and prisons with mental illness quadrupled in just six years — from 283,000 in 1998 to 1.25 million in 2006. This surge coincided with the closure of the last of the hospitals.

The magnitude of the problem is evident upon examination of prison statistics in Connecticut, where the adult population of people incarcerated with moderate to severe mental illness has increased from 2,200 in 2000 to 3,700 in 2005, or from 12 percent to 20 percent.

With few inpatient beds and no law that allows for assisted outpatient treatment, the citizens of Connecticut with severe mental illnesses aren’t left with many options.

New book: Crazy in America

GUEST BLOG:

Written by Mary Beth Pfeiffer, author of “Crazy in America: The Hidden Tragedy of Our Criminalized Mentally Ill”.

"Children wait in emergency rooms for psychiatric beds, sometimes for days."
--- June 1, 2007, Hartford Courant editorial.

We all know that America had better than a half-million psychiatric hospital beds 50 years ago, beds that were whittled down in a great, silent wave of untethered humanity called deinstitutionalization. But few realize that deinstitutionalization is continuing, and so is the failure of community care to pick up the slack.

The children referred to in the quotation above, who suffer while waiting for psychiatric beds in Connecticut, are just one group of victims. Add to them the homeless, the incarcerated, the two-thirds of Americans with mental illness who go untreated.

From 1990 to 2000, long after deinstitutionalization was believed over, the nation lost an additional 57,000 psychiatric beds, bringing the total to 86,000. But the bloodletting didn’t stop there: Harrisburg State Hospital closed in Pennsylvania last year and with it 260 beds. In Florida, 36 private psychiatric hospitals have closed in since 1992 – taking 4,400 beds. In Iowa, 600 general-hospital psychiatric beds were shuttered from 1998 to 2002 -- nearly half the state’s total. Connecticut had three sprawling public mental hospitals in the 1950s, serving 9,000; with additional cuts in recent years it is down to about 600.

America’s system of mental health care is broken. Emergency rooms, which saw psychiatric cases rise by 56 percent from 1992 to 2003, take the brunt in this severely strained system. And jails and prisons act as de facto mental institutions where there is always a bed – and where at least 330,000 mentally ill people now reside.

America needs leadership on mental health care. We need leaders who are willing to equate the needs of people with mental illness with those who suffer from cancer and heart disease. We need legislators willing to provide funding for housing, clinics and subsidized insurance. We need a media willing to explore the ills of a forgotten and under-funded system.

This isn’t too much to ask.
---Mary Beth Pfeiffer

***
Visit Mary Beth Pfeiffer’s web site at www.crazyinamerica.com to see photographs of her profile subjects and get other information. To buy the book, go to http://www.amazon.com/Crazy-America-Tragedy-Criminalized-Mentally/dp/0786717459/ref=pd_nr_b_8/103-2156816-0667067?ie=UTF8&s=books.

The opinions expressed by guest bloggers are their own and not necessarily that of the Treatment Advocacy Center.

Want to be a guest blogger? Tell us why at info@treatmentadvocacycenter.org.

Closing state hospitals doesn't eliminate need for care

The use of general hospitals to treat serious mental illnesses increased 34.7% between 1995 and 2002 according to a new study published in Psychiatric services this month. This raises a number of questions, not the least of which is whether psychiatric units in general hospitals are equipped to provide the kind of treatment, rehabilitation and discharge planning that state psychiatric hospitals can provide.

Take Virginia for instance. In 2006, the average length of stay for acute admissions to a state psychiatric hospital was 47.2 days compared to 5.4 days in community psychiatric inpatients beds. The abbreviated treatment provided in general hospital psychiatric beds may account for these hospitals’ “revolving doors” through which 3,514 patients passed 3 or more times in 2002 at a cost of about $111 million. Maybe closing state psychiatric hospital isn’t such a good thing – for patients or budgets.

Analysis of U.S. Trends in Discharges From General Hospitals for Episodes of Serious Mental Illness, 1995–2002, Shinobu Watanabe-Galloway, Ph.D. and Wanqing Zhang, M.D., M.Ed., Psychiatr Serv 58:496-502, April 2007

No beds in Oregon

In a recent article, Joseph D. Bloom, M.D. correlates the significant drop in civil commitments in Oregon over the past 20 years to the virtual disappearance of psychiatric inpatient beds. While the number of investigations for civil commitment have more than doubled over the last 20 years (from 3996 to 8315), the number of actual commitments has dropped by a third (1165 to 785). The other dramatic change in Oregon is the number of civil psychiatric beds. The state psychiatric hospital system has a total of 741 beds, of which 307 (41%) are civil beds and 434 (59%) are designated for the forensic system. Dr. Bloom concludes that it is primarily the decrease in available beds that has resulted in reduced inpatient commitments rather than a reduced need for commitment. Based on his analysis, he warns that:

The use of civil commitment as a method of diverting individuals from the criminal justice system to the mental health system has been replaced by diversion from one part of the criminal justice system to another, from jails to mental health courts. Reversing this trend toward criminal justice sanctions will take a concerted effort to restore civil commitment to a meaningful place in the mental health system.

Criminal justice professionals should heed Dr. Bloom’s warning if they don’t want to see their jobs permanently transformed into being mental health professionals. Law enforcement and corrections officials should be advocating the restoration of a meaningful civil commitment system, both inpatient and outpatient.

Deinstitutionalization knows no borders

“Canada is not alone in jailing the mentally ill. The United States, too, deinstitutionalized a large number of psychiatric patients. There, too, law-enforcement agencies increasingly are left to pick up the pieces.

In New York City, according to statistics compiled by the Treatment Advocacy Centre, the number of police responses to complaints about "emotionally disturbed persons" climbed from 20,843 in 1980 to 64,424 in 1998. In Florida, mentally ill people in crisis must be assessed under the state's mental-health treatment law. In 2000, there were 80,869 mental-health assessments, a figure that handily surpassed the 60,337 drunk driving arrests that year.”

More from the Montreal Gazette …

For more information on ensuring appropriate treatment for people with severe mental illnesses in Canada, visit: http://www.cfact.ca/

Hurricane Katrina and the treatment crisis

In New Orleans, Hurricane Katrina decimated the city’s psychiatric services.

In the 16 months since the storm hit, the number of hospital beds has plummeted. Remaining facilities have limited space and people in crisis often end up being treated by – or held in – the city’s emergency rooms until a bed opens up somewhere else. And as for police, “two officers always escort psychiatric patients to emergency rooms, where they often must wait for hours until the hospital can accept them. The wait prevents officers from patrolling.”

Some small measure of relief may be coming in the form of a new psychiatric facility.

"That would be tremendous," [Dr. Joseph ] Guarisco [chairman of emergency medicine at Ochsner Medical Center] said. "Psych is our No. 1 crisis right now in the emergency department. The city's outpatient and inpatient psych capacity was plundered by the storm. We have been inundated with chronic mental illness without any available resources for these patients."

The country overall is facing very similar problems. Just because it took 40 years to reach this crisis nationwide doesn’t mean it isn’t worth addressing just as aggressively.

Our national system was plundered by a different kind of storm, waged not by nature, but by well-meaning advocates who saw all hospitals as negative and all commitment laws as paternalistic.

Required reading for psychiatrists ...

In Crazy, Earley provides a remarkable and fresh look at the US mental health system. He does so in a balanced, honest, self-reflective, and informed way. Crazy offers a unique and sensitive perspective on questions America is reluctant to address. It should be required reading for psychiatry residents, forensic fellows, and any psychiatrist interested in public sector psychiatry ...

Placing his argument in historical context, he describes deinstitutionalization as a well-intentioned but poorly reasoned outgrowth of the antipsychiatry movement, which began in the 1960s ... Earley describes deinstitutionalization as an "unplanned social disaster," which ... has created an environment as abusive to the mentally ill as the dreaded state hospitals of the past ... Earley poignantly reflects on a society that accepts homelessness as a civil right ...

- Journal of the American Medical Association (JAMA), January 2, 2007