Return to Involuntary Institutionalization?

Psychiatric hospital in Scotland
In 1963 President Kennedy signed The Community Health Centers Act. The purpose of the Act was to deinstitutionalize the mentally ill and support them through community mental health clinics. The law drew enthusiastic bipartisan support. Fiscal conservatives were interested in saving funds by shutting state hospitals. Civil rights advocates believed that mental patients needed to be liberated. This was the last law Kennedy signed before his assassination.

Mass deinstitutionalization has been an unmitigated disaster. The federal grants promised to the states for community mental health clinics barely materialized. Most communities did not have the facilities to deal with the hundreds of thousands that were released. In many cases, patients wound up homeless or in jails.

Fifty years later we’re now seeing bipartisan support to consider increasing institutionalization, when necessary, especially those with the most serious mental illnesses, such as schizophrenia and bipolar disorder. The December 1st issue of Time has an excellent article titled “Dangerous Cases,” written by Haley Sweetland Edwards, about the growing concerns of what to do with the seriously mentally ill.

Why the change in attitude? Much of it has to do with the onslaught of mass shootings throughout the United States. Some believe we need better gun control, while some believe we need to reform our mental health care. The article quotes a Gallup poll that asked about the cause of mass shootings and the majority of Americans blamed the health care system “for failing to identify dangerous individuals than the availability of guns.” It goes on to ask, “Should it be easier to compel adults with a serious mental illness…to receive involuntary psychiatric treatment?”

The article goes on to state, “Only 3% to 5% of violent crimes in the U.S. can be attributed to mental illness, according to Duke medical sociologist Jeffrey Swanson, but such tragedies like the 2012 shootings at Sandy Hook Elementary in Newtown, Connecticut, in which a man killed 20 children and 6 adults, or the 2007 Virginia Tech shooting, in which a student with a mental illness killed 32 people – tend to have a disproportionate impact. They earn headlines, anger the public and motivate politicians to action in a way that the mundane suffering of the homeless or convicted criminals does not.”

While the mass shootings are frightening and do demand we look at how we treat the mentally ill in America, it’s not the only reason we’re seeing changes in how we view involuntary institutionalization. The reason liberals and conservatives have united in 2014 are the very same reasons they were united in 1963 – humanitarian and fiscal responsibility. “Liberals who once opposed any form of involuntary treatment on civil rights grounds now find the alternative – mass homelessness, incarceration and victimization – to be morally repugnant. They are joined by fiscal conservatives, who once decried the cost of government run state institutions but now find it’s costlier to provide for large populations of inmates with mental illnesses.”

My concern regarding this change in perspective is because the 1963 The Community Health Centers Act didn’t fail – it was never given a chance. The local health centers, which were the integral part of the program, never opened. Over a decade ago I knew I needed help and I sought it, but I was repeatedly turned away from county clinics. They didn’t have the money or the resources to take me in as a client. My inability to get help I needed landed me in a psych ward. When it came time for me to be released the hospital couldn’t find a clinic for me either. In the end they weren’t able to get me into the Hollywood clinic, which was an easy walk from where I live. The only county clinic they were able to place me was a three hour bus trip each way. Even though it’s been 50 years, to say the system failed and return to involuntary institutionalization is premature.

I believe the solution is to have a three-tiered system. First, is to finally build the local mental health clinics as Kennedy envisioned them. These would be voluntary clinics for people seeking needed care.

Secondly, should a person not seek the help they need or refuse help, there is another option that was enacted in some states called assisted outpatient treatment (AOT). The laws in states vary but the concept is the generally the same. Judges have the power to order a person with mental illness into treatment if the person has been “recently and repeatedly hospitalized or arrested as a result of his illness, or committed or threatened a serious act of violence on himself or others. Under AOT, a patient can’t be forced to take medication; if he refuses treatment, a team of health care workers tasked with providing what’s known as wraparound care must simply monitor him to ensure he remains stable.” Interestingly enough, most states have had AOT laws for years, yet New York is the only state which funded it all at the local level. The hesitancy is because AOT is expensive, however, in the long run it could save states money. Currently it costs Americans $317 billion to care for the seriously mentally ill.

My third and final tier would be involuntary institutionalization, but only for the most serious patients, and with rigid laws which determine when it is necessary.

Whatever laws and procedures are put in place, I hope they are fiscally responsible and humane. Currently, I fear our society will react emotionally and send us back to pre-1960’s care.

  6 comments for “Return to Involuntary Institutionalization?

  1. December 17, 2014 at 12:28

    Interestng post. However, I want to make one point about AOT. Its effectiveness has been tested, but not against similar programs that are not enforced (simply because informal care is usually less substantial than enforced care). This means that people who do seek care, cannot get as much care as those under AOT. This in turn means that it’s not been proven that the force in AOT works, but simply that the intensiveness of the care works. I would love to get intensive outpatient care, but here in the Netherlands, from 2015 on, either you fall under the long-term care act (ie. institutionalization) or you live outside of an institution and fall under the community assistance act. The long-term care act guarantees intensive care for the rest of their lives to those most in need. However, if you fall under the community assistance act, you’re at the mercy of local governments that face massive budget cuts. There are some laws in the making aroudn enforced mental health treatment (currently we only have a law allowing involuntary hospitalization, not AOT).

    • Bradley
      December 17, 2014 at 12:55

      I’m learning now that this is not an American problem – it’s a global problem. The only way each tier can work is if all parties are given the money and the resources they need. Otherwise, we fall back on incarceration or institutionalization as the primary form of care.

      It’s becoming clear to me that it all comes down to money. If it’s too expensive then it appears society’s answer is to just throw the mentally ill away.

  2. December 17, 2014 at 12:03

    Excellent article. Very well thought out. I agree with the three-tier plan and resource allocation you envision.

    • Bradley
      December 17, 2014 at 12:16

      Thank you, Kitt

  3. December 17, 2014 at 10:25

    In Canada I think we have some significant parallels. Community support is very hard to obtain, often more so for those of us who are comparatively functional. Our current government government has a very conservative law and order agenda even though our crime rate does not match the US by any means (and our gun laws are infinitely tighter), but the most sensational crimes which frequently have a clear mental health component get undue attention and NCR (Not Criminally Responsible) findings are met with outrage. I once fought for an NCR for brain injured mentally ill client I worked with who had exhausted all community resources and was more vulnerable than dangerous. The few years of institutionalized care the designation provided would at least provide a healthy, supported environment and release. Unfortunately, with such a massive reduction in longer term psychiatric institutions, the prisons become the default placement for so many with serious mental health and addictions. That is not the answer.

    Finding the balance is the challenge of course and an effective appeal system to help ensure that inconvenient mentally ill people are not simply locked away rather than receiving appropriate treatment and support.

    • Bradley
      December 17, 2014 at 12:10

      Wow. That’s surprising to hear. I think here in the states we tend to think of Canada as having the perfect health care system, but I guess you all are human like the rest of us. 🙂

      Prisons are not the answer. They are dangerous for a person with mental illness and they are very expensive. Unfortunately, that’s being used as the primary course of action.

      Former Los Angeles, Sheriff Lee Baca once said: “I run the biggest mental hospital in the country.” And the sad part is that he was statistically accurate.

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