How To Deal With Mentally Ill People – The “deinstitutionalization” movement was intended to correct the flow of neglected patients, depressed and vulnerable staff, and absentee physicians. It didn’t happen.
Note to Readers: This is a companion piece to the original interview by Awais Aftab, MD, Discussions in Critical Psychiatry: Allen Francis, MD. We are grateful to both Dr. Aftab and Dr. Francis for their contributions.
How To Deal With Mentally Ill People
Dr. Francis is Professor Emeritus and former Chair of the Department of Psychiatry at Duke University; Chair of the DSM-IV Working Group; and the author
Nimh » Caring For Your Mental Health
My career ends on a sour note. When 600,000,000 people who should be our patients are instead tired like prisoners or sleeping rough on the streets. City jails currently provide mental health care for people with severe mental illness. And our patients are incarcerated for long periods of time, often in solitary confinement, and often subjected to sexual and sexual abuse. I saw long rows of cells, in each of which there was a very dirty mental patient with dirt on the walls and windows.
We have no excuse for collectively failing the patients who need us most. It’s easy for each of us to blame the system – government neglect, professional inaction and campaign groups for missing the message – but I also blame myself for doing too little, too late. We are all part of the system and must take responsibility for its wrongdoings.
We can’t fix this mess if we don’t understand its history. State mental hospitals in the 19th century had both good intentions and negative consequences. Their goal was humane treatment for the mentally ill according to the principles promulgated by the father of modern psychiatry, Phillip Pinel. The asylum was intended to be a peaceful retreat in the countryside, providing safety and a meaningful life for the mentally ill who could not find a place in the fast-growing cities. The hospital was the only community that was peaceful, civilized and hospitable. Surrounding it are workshops and areas that allow patients to learn skills and feel productive. Hospital administrators, employees and families lived in the square and shared bread with the patients. The architecture of the building was usually very beautiful and it was surrounded by a beautiful garden.
In the 20th century there was a rapid and complete breakdown of the system due to overcrowding and poor maintenance of the system. The personnel profession has divided the medical profession. Cities are growing surrounded by and surrounded by hospitals, keeping patients for endless days in dirty, crowded and smelly wards. Trade unions approve of job competition for low-paid or unpaid workers and press for the closure of shops. A good shelter had turned into a pit of horror.
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My first experience in psychiatry was 55 years ago as a medical student in a public hospital. It was humiliating and disgusting—the smell of urine, the screams of neglected patients, the incompetent and incompetent staff, the missing doctors.
The “deinstitutionalization” movement that sought to fix the mess was born out of a curious combination: public outrage; new model of psychiatry; discovery of important new drugs; The Kennedy Family Crime; government greed. Three books played a big role.
The 1946 autobiographical novel by Mary Jane Ward (made into a popular film in 1948) was a vivid depiction of the suffering of terror patients.
, written in 1961 by psychiatrist Tom Sass, proposed the ethical and legal theory that patients are citizens with civil rights that must be respected.
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He noted that institutionalization made patients sicker and more dependent than they had been in any insane asylum.
Psychiatry predicts a happy life for psychotic symptoms suppressed by new antipsychotic drugs that are independent, resocialized and effective in the population. John F. Kennedy’s experience with his sister’s mental illness inspired him to support the Mental Health Care Act, which provided funding for community health centers (CMHCs) across the United States. All state governments were desperate to close the massive psychiatric hospitals that had previously been a drain on the budget.
Deinstitutionalization was a bad thing. Patients who had spent decades in the hospital were often thrown out on the street with a week’s notice. One day after leaving the state hospital that had been his home and business for 22 years, a man walked into my intensive care unit. He had achieved great status and relative wealth as a car wash worker. Now he is confused and cannot imagine a new life for himself without transition and support. After a few days, I had to hang him in the bathroom.
CMHC finally lived up to expectations and was a fun place to work. We have seen many of our patients thrive away from harmful public environments. Long-term symptoms appear to be reduced using a combination of new medications, rehabilitation, and socialization. Until the 1970s, the United States was the model and world leader in segregation and segregation.
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Then, in the 1980s, the Reagan administration killed a system that cut off direct government funding for CMHCs and replaced it with federal freeze funding that was rarely used for mental health services and eventually ended entirely. It was motivated by the ideology of reducing government spending and giving more power to the government, but it was mainly a way to reduce taxes for the rich.
This catastrophe followed two periods of deinstitutionalization and the closing or privatization of CMHCs. Before segregation there were about 650,000 public beds in the United States, now the population has more than doubled, we have about 35,000 beds.
Whereas before the “snake” warehouse housed many patients far away, now even for those who need it the most, it is impossible to find a bed and the stay is very short.
It is not possible to treat very sick patients at all or for a month or more. Emergency rooms are filled with critically ill patients, but they have nothing to show for it. Realizing that taking the mentally ill to the emergency room is a waste of time, regular first responders now have to take them to the jail instead. And having to constantly deal with people with untreated and untreated mental illness probably appealed to some police officers.
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With legions of patients incarcerated and homeless, America has become the worst place in the world for serious mental illness. The best places where the model of mental illness is well known – especially the city of Trieste and the Nordic countries.
The protection of the mentally ill was silent and ineffective. It is sad to see strong evidence of better care from police and sheriff’s organizations that people should be in the mental health system. Psychiatric and psychological organizations have become so pastoral – they have never forgotten the shame of neglecting the seriously ill in the first place. NAMI began as an advocacy group for better treatment for the critically ill, but has since lost sight of its mission — often distracted by a lack of faith in scientific research and the development of new drugs.
Relying on future research is a case of blindly hoping for a failed experiment. NIMH has spent billions on exciting science that has yet to help a single patient. The human brain is the most complex thing in the known world and keeps its secrets well. Genetics and neuroimaging have shown how complex and interactive biopsychosocial factors lead to mental illness and that they are never fatal. Drug companies have stopped looking for it.
NIDA focused too much on brain activity and largely ignored the practical issues that improve the quality of life of people with addiction. Until recently, SAMHSA primarily funded projects that were completely disconnected from the needs and pain of acute care patients. The Treatment Advocacy Center (https://www.treatmentadvocacycenter.org) is the only group dedicated to researching the needs of vulnerable patients, speaking truth to power, and giving voice to the voiceless.
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We need a mind that looks like the moon and that doesn’t require rocket science or innovation. For 50 years we know how to provide the best care for serious mental illness. There is nothing special or difficult about it. Beautiful houses. Easy treatment. Social networks. Career opportunities. Be kind, respectful and compassionate. Family support. The only thing new is the use of the Internet as a powerful tool for education, social networking and tracking.
The #1 priority is to get patients out of jail and off the street. Segregation programs have proven effective in preventing incarceration and should be adopted worldwide. Prison desegregation programs must now be developed to “deinstitutionalize” wrongfully incarcerated mentally ill people and provide them with better community housing and care.
Neglecting the critically ill is not only cruel, but also unwise. prison,
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