Patrick Moynihan: Deinstitutionalization Failed

2 articles
Congressional Record – Senate

Monday, July 12, 1999

106th Congress, 1st Session, 145 Cong Rec S 8295, Vol. 145, No. 97

Deinstitutionslization of the mentally ill


Mr. President, this past Friday (July 9, 1999),The Washington Post carried an excellent op-ed piece, “Deinstitutionalization Hasn’t Worked,” by E. Fuller Torrey and Mary T. Zdanowicz. The authors are the president and executive director, respectively, of the Treatment Advocacy Center. They write about the continued stigma attached to mental illness. They write about barriers to treatment. Most important, they write about the aftermaths of deinstitutionalization, and the seemingly horrific effects this policy has had.

In this morning’s New York Times (July 12, 1999), Fox Butterfield writes about a Department of Justice report released yesterday which states that some 283,800 inmates in the nation’s jails and prisons suffer from mental illness. (This is a conservative estimate.) As Butterfield puts it, “. . . jails and prisons have become the nation’s new mental hospitals.”

Over the past 45 years, we have emptied state mental hospitals, but we have not provided commensurate outpatient treatment. Increasingly, individuals with mental illnesses are left to fend for themselves on the streets, where they victimize others or, more frequently, are victimized themselves. Eventually, many wind up in prison, where the likelihood of treatment is nearly as remote.

This is a cautionary tale, instructive of what is possible and also what we ought to be aware of. I was in the Harriman administration in New York in the 1950s. Early in 1955, Harriman met with his new Commissioner of Mental Hygiene, Paul Hoch, who described the development of a tranquilizer derived from rauwolfia by Dr. Nathan S. Kline at what was then known as Rockland State Hospital (it is now the Rockland Psychiatric Center) in Orangeburg. The medication had been clinically tested and appeared to be an effective treatment of many patients. Dr. Hoch recommended that it be used system wide; Harriman found the money.

That same year Congress created a Joint Commission on Mental Health and Illness with a view to formulating “comprehensive and realistic recommendations” in this area which was then a matter of considerable public concern. Year after year the population of mental institutions grew; year after year new facilities had to be built. Ballot measures to approve the issuance of general obligation bonds for building the facilities appeared just about every election. Or so it seemed.

The discovery of tranquilizers was adventitious. Physicians were seeking cures for disorders they were just beginning to understand. Even a limited success made it possible to believe that the incidence of this particular range of disorders, which had seemingly required persons to be confined against their will or even awareness, could be greatly reduced. The Congressional Commission submitted its report in 1961; it was seen to propose a nationwide program of deinstitutionalization.

Late in 1961 President Kennedy appointed an interagency committee to prepare legislative recommendations based on the report. I represented Secretary of Labor Arthur J. Goldberg on this committee and drafted its final submission. This included the recommendation of the National Institute of Mental Health that 2,000 “community mental health centers” (one for every 100,000 people) be built by 1980. A buoyant Presidential Message to Congress followed early in 1963. “If we apply our medical knowledge and social insights fully,” President Kennedy stated, “all but a small portion of the mentally ill can eventually achieve a wholesome and a constructive social adjustment.” A “concerted national attack on mental disorders [was] now possible and practical.” The President signed the Community Mental Health Centers Construction Act on October 31, 1963 — his last public bill signing ceremony. He gave me a pen.

The mental hospitals emptied out. The number of patients in state and county mental hospitals peaked in 1955 at 558,922 and has declined every year since then, to 61,722 in 1996. But we never came near to building the 2,000 community mental health centers. Only some 482 received Federal construction funds from 1963 to 1980. The next year, 1981, the program was folded into the Alcohol, Drug Abuse, and Mental Health block grant program, where it disappeared from view.

Even when centers were built, the results were hardly as hoped for. David Musto has noted that the planners had bet on improving national mental health “by improving the quality of general community life through expert knowledge [my emphasis], not merely by more effective treatment of the already ill.” The problem was: there is no such knowledge. Nor is there. But the belief there was such knowledge took hold within sectors of the profession, which saw institutions as an unacceptable mode of social control. These activists subscribed to a redefining mode of their own, which they considered altruistic: mental patients were said to have been “labeled,” and were not to be drugged. So as the Federal government turned to other matters, the mental institutions continued to release patients, essentially to fend for themselves. There was no connection made: we’re quite capable of that in the public sphere. Professor Frederick F. Siegel of Cooper Union observed: “in the great wave of moral deregulation that began in the mid-1960s, the poor and the insane were freed from the fetters of middle-class mores.” Soon, the homeless appeared. Only to be defined as victims of an insufficient supply of affordable housing. No argument, no amount of evidence has yet affected that fixed ideological view.

I commend these two articles to my colleagues and ask that they be printed in the Record.

Deinstitutionalization hasn’t worked

‘We have lost effectively 93 percent of our state psychiatric hospital beds since 1955.’

By E. Fuller Torrey, M.D. and Mary T. Zdandowicz, J.D.
The Washington Post
July 9, 1999

The White House Conference on Mental Health identified stigma and discrimination as the most important barriers to treatment for the mentally ill. For the most severely ill, there are more significant barriers to treatment such as laws that prevent treating individuals until they become dangerous. These laws and our failure to treat individuals with schizophrenia and manic-depressive illness are, ironically, the leading causes of stigma and discrimination against those with mental illnesses.

Stigma is created by the sort of headlines that result when a person is not being treated for mental illness and shoots two Capitol police officers to death or pushes an innocent victim in front of a speeding subway train. Some 20 years of research, in fact, has proven this point.

A 1996 study published in the Journal of Community Psychology demonstrated that negative attitudes toward people with mental illnesses greatly increased after reading newspaper articles reporting violent crimes by the mentally ill. Henry J. Steadman, an influential public opinion researcher, wrote as far back as 1981, “Recent research data on contemporary populations of ex-mental patients supports these public fears [of dangerousness] to an extent rarely acknowledged by mental health professionals. . . It is [therefore] futile and inappropriate to badger the news and entertainment media with appeals to help destigmatize the mentally ill.”

Tipper Gore and the White House must tackle 30 years of failed deinstitutionalization policy if they hope to win the battle of mental illness stigma and solve the nation’s mental illness crisis. Hundreds of thousands of vulnerable Americans are eking out a pitiful existence on city streets, under ground in subway tunnels, or in jails and prisons due to the misguided efforts of civil rights advocates to keep the severely ill out of hospitals and out of treatment. The images of these gravely ill citizens on our city landscapes are bleak reminders of the failure of deinstitutionalization. They are seen huddling over steam grates in the cold, animatedly carrying on conversations with invisible companions, wearing filthy, tattered clothing, urinating and defecating on sidewalks or threatening passersby. Worse still, they frequently are seen being carried away on stretchers as victims of suicide or violent crime, or in handcuffs as perpetuators of violence against others.

All of this occurs under the watchful eyes of fellow citizens and government officials who do nothing but shake their heads in blind tolerance. The consequences of failing to treat these illnesses are devastating. While Americans with untreated severe mental illnesses represent less than one percent of our population, they commit almost 1,000 homicides in the United States each year. At least one-third of the estimated 600,000 homeless suffer from schizophrenia or manic-depressive illness, and 28 percent of them forage for some of their food in garbage cans. About 170,000 individuals, or 10 percent, of our jail and prison populations suffer from these illnesses, costing American taxpayers a staggering $8.5 billion per year.

Moreover, studies suggest that delaying treatment results in permanent harm, including increased treatment resistance, worsening severity of symptoms, increased hospitalizations and delayed remission of symptoms. In addition, persons suffering from severe psychiatric illnesses are frequently victimized. Studies have shown that 22 percent of women with untreated schizophrenia have been raped. Suicide rates for these individuals are 10 to 15 times higher than the general population.

Weak state treatment laws coupled with inadequate psychiatric hospitals beds have only served to compound the devastation for this population. Nearly half of those suffering from these insidious illnesses do not realize they are sick and in need of treatment because their brain disease has affected their self-awareness. They do not recognize that the symptoms of their illness – hallucinations, delusions, paranoia, and withdrawal – are, in fact, symptoms. Since they do not believe they are sick they refuse medication.

Most state laws today prohibit treating individuals over their objection unless they pose an immediate danger to themselves. In other words, an individual must have a finger on the trigger of a gun before any medical care will be prescribed.

Studies have proved that outpatient commitment is effective in ensuring treatment compliance. While many states have some form of assisted treatment on the books, the challenge remains in getting them to utilize what is at their disposal rather than tolerating the revolving-door syndrome of hospital admissions, readmissions, abandonment to the streets and incarceration that engulfs those not receiving treatment.

Adequate care in psychiatric facilities also must be available. Between 5 and 10 percent of the total 3.5 million persons suffering from schizophrenia and manic-depressive illness require long-term hospitalization – which means hospitalization in state psychiatric hospitals. This critical need is not being met since we have lost effectively 93 percent of our state psychiatric hospital beds since 1955.

It is time to recognize that feel-good mental health policies have caused grave suffering for those most ill and that real solutions must be developed. The lives of millions of Americans depend on it.

Reprinted with permission. Copyright 1999 The Washington Post. All rights reserved.