HCR -- Deinstitutionalization (with Addendum)

By John Ballard

A San Diego woman identifying herself as the mother of Colorado theater shooting suspect James Holmes told a news crew Friday morning that authorities "have the person," ABC news reports.

The woman, who said her name was Arlene, had awoken unaware of the news of the shooting and had not been contacted by authorities. She immediately expressed concern that her son may have been involved.

"You have the right person," the mother said, speaking on instinct. "I need to call the police. I need to fly out to Colorado."

This snippet among the first hours of yesterday's reports of Colorado's latest mass killing spree says more than any of the other reports. 

?ADDENDUM: Arlene Holmes now states (Monday, July 23)  that when she spoke to the reporter she was not implicating her son but was identifying herself as the correct person they were trying to reach. 
Like so many early reports and speculations, this may or may not have any bearing on the final outcome of this tragic course of events. That said, I am leaving the rest of this post as is. Just as the link to a story about Jesse Jackson, Jr. is not about him, this post is not about James Holmes.

This post is about the problems and tragedies of deinstitutionalization.

It should be noted that at least one individual, a man making arrangements for a training class, directed that James Holmes not be admitted because of his behavior and a "bizarre" message on his voice mail greeting.  

I have previously blogged about the problems precipitated by the unfortunate, misguided Sixties trend of deinstitutionaliztion here and here. I refer readers to those posts from January, 2011 for background reading. My personal first awareness of the problem is at the first link. A repeated screed from the second will end this post.

Readers are smart enough to follow the next links and connect the dots. As usual, I won't insult anyone by stating what is obvious.

?A National Disorder
What the Jesse Jackson, Jr., case suggests about mental illness in America. 

==>  [This is NOT about Jesse Jackson, Jr.  If you think it is you need to clear your head, take a deep breath and start over.]  <==

...Jackson is likely getting some of the best possible care. If he entered a facility on or around the start of his leave June 10, then he has been in treatment for a month-practically an eternity in today's health care environment. While you still encounter jokes in movies and television about "committing" someone for life, that has been exceedingly rare for some time, thanks to the deinstitutionalization movement. That movement was favored both by politicians like Ronald Reagan, who saw it as a cost-cutting measure, and by advocates for those who suffer from mental illness, who believed that community-based treatment could be more effective and more humane.

In recent years, cash-strapped states have continued to cut funds for psychiatric patients' care. In February, for instance, Alabama announced plans to shutter most of its facilities by the spring of 2013. Last fall, Vermont officials struggled to find beds for 51 very ill patients after their hospital was left unusable after flooding caused by Tropical Storm Irene. Jackson's home state of Illinois reduced general funds for mental health by 31.7 percent-or more than $113 million-between 2009 and 2011, according to a report by the National Alliance for the Mentally Ill.

The result: On average, hospitalizations for the mentally ill last just 7.5 days. And this isn't entirely a bad thing. It's not fun to be in a psychiatric facility, whether as a visitor or a patient. The idea is to get people stable so they can return quickly to society. But that isn't always enough time. Jackson, it would appear, has the unusual benefit of recovering at the speed his doctors deem necessary, rather than being limited by insurance companies or state resources.

There is much more at the link, including some personal remarks by the journalist who wrote the piece. Read it all. In this conversations there is no need to make anyone's opinions out of order. 

?Treatment Advocacy Center Study Shows State Hospital Bed Numbers Plunge to 1850 Levels Patients, Jails, Emergency Rooms and Public Safety Are Affected

If the dateline is correct -- July 19, 2012, 6:00 a.m. EDT --  this prescient article appeared literally a few hours before yet another tragedy which was about to unfold in Colorado. 

The number of public hospital beds for people in acute psychiatric crisis plunged in 2010 to levels not seen since 1850, exerting profound impacts on patients, law enforcement, jails, hospitals and public safety, according to a new study released today by the Treatment Advocacy Center. "No Room at the Inn: Trends and Consequences of Closing Public Psychiatric Hospitals" reports that state hospital bed numbers dropped 14% from 2005 to 2010, falling to 43,318 beds nationwide. This compares with 50,509 beds in 2005 and 558,922 in 1955, the peak year of psychiatric hospitalization before the trend known as "deinstitutionalization" began.

The Treatment Advocacy Center called for a moratorium on further public hospital bed closures until a sufficient number of psychiatric beds for acutely and/or chronically ill individuals is available, either in state hospitals or community facilities.

"The elimination of hospital beds for people who are psychotic or otherwise acutely or chronically disabled by severe mental illness endangers them and society at large," said Doris A. Fuller, executive director of the Treatment Advocacy Center and a co-author of the study.

"These closures are creating enormous strains on law enforcement, jails, prisons and hospital ERs, where acutely ill people are essentially 're-institutionalized'-or left to live on the streets," she said. "Wherever they are, they exist in an alternate reality that deprives them of the ability to participate in life as they could with treatment."

?When My Crazy Father Actually Lost His Mind

This is the most readable and heart-breaking of the links I have listed. I urge the reader to take time to read the whole thing. Something about a personal account gives a human dimension to otherwise clinical-sounding discussions. You always know when someone has skin in the game. 

Until the late 19th century, mentally ill people were locked in prisons or left to wander the streets. Reformers, seeking a more humane response, created a vast system of state-run psychiatric hospitals. By the 1960s, however, the overcrowded, often disturbing conditions in those facilities had come to light. At the same time, new psychiatric medicines were being developed, all of which gave rise to a new reform effort. Deinstitutionalization, the systematic closure of state psychiatric hospitals, was codified by the Community Mental Health Centers Act of 1963 and supported by patients' rights laws secured state by state. Chief among those laws were strict new standards: only people who posed an imminent danger to themselves or someone else could be committed to a psychiatric hospital or treated against their will. By treating the rest in the least-restrictive settings possible, the thinking went, we would protect the civil liberties of the mentally ill and hasten their recoveries. Surely community life was better for mental health than a cold, unfeeling institution.

But in the decades since, the sickest patients have begun turning up in jails and homeless shelters with a frequency that mirrors that of the late 1800s. "We're protecting civil liberties at the expense of health and safety," says Doris A. Fuller, the executive director of the Treatment Advocacy Center, a nonprofit group that lobbies for broader involuntary commitment standards. "Deinstitutionalization has gone way too far." According to Fuller's group, there was one public psychiatric bed for every 300 Americans in 1955; by 2012, that number was one for every 7,000. That's less than a third of what is needed, the organization asserts. The recession has made matters worse: since late 2008, more than $1.5 billion has been cut from state mental health budgets across the country. In the past two years alone, 12 state hospitals with a total of nearly 4,000 beds have either closed or are in danger of closing.

Already patients in crisis can spend several days in an emergency room waiting for a psychiatric bed to become available. In New Jersey, it can take as long as five days; in Vermont - where, as Bloomberg News recently reported, there are virtually no state psychiatric beds left - severely mentally ill patients have been handcuffed to emergency-room beds. For lack of other options, many patients who clearly meet the imminent-danger standard are released. "The lack of resources has triggered a devolution of the standard," says Robert Davison, executive director of the Mental Health Association of Essex County, a nonprofit group that connects patients to services in northern New Jersey. "Twenty years ago, 'imminent danger' meant what most people think it means. But now there's this systemic push to divert people away from inpatient care, no matter how sick they are, because we know there's no place to send them."

When I asked Davison for specific examples, he rattled several off the top of his head. A man who was convinced that aliens were on the roof and that bugs were coming out of the walls and who would not sit on furniture but only lie on the floor was not committable. Neither was the man who refused medication and mutilated his own testicles. Nor the woman who wouldn't eat because she believed the C.I.A. was trying to poison her. "It is unbelievable the condition of people who are found not to meet the standard," Davison says.

?Media exploits Colorado shooting to push gun control

This piece is nakedly partisan. Feeding off the Twitter feeds and vacuous early remarks of talking heads and reporters filling air time with speculations, Anthony Martin (Conservative examiner) joined the fray with the term "mainstream" media," an epethet almost never used by us subversive types from the OWS ranks. He does, however, get a core message right when he cites the background of deinstitutionalization. 

...America has a problem lurking under the surface with which it had just as soon not deal -- millions of mentally ill who are no longer required to be in treatment facilities, mainly due to the national lobby for the rights of the mentally ill, the National Alliance for the Mentally Ill (NAMI).

During the 1970s NAMI began pushing for the release of mentally ill patients from hospitals, claiming that their rights had been violated. Beginning with the administration of President Jimmy Carter and continuing throughout the 1980s and 90s, mental hospitals all across the country were forced gradually to release most if not all of their patients. These patients had been deemed by physicians and the courts to be mentally unfit for society. A large number of these persons were commonly known as "criminally insane" in that they had committed acts of violence.

This process was known at the time as "deinstitutionalization" and resulted in mass homelessness during the 1980s.

This reporter witnessed this scenario first hand while in clinical training for mental health chaplaincy. The hospital that provided the training was forced to meet with NAMI on a monthly basis to discuss issues of patients' rights. Physicians, nurses, and other hospital personnel told this reporter at the time that NAMI had been singularly responsible for the release of hundreds of patients through the years.

Prior to the mass release of patients in the 1970s, the hospital at one time had served over 2,000 patients. By the time this reporter began training at the facility, that number had plummeted to a mere 300 patients. [This observation, incidentally, exactly reflects my own experience as I reported in the second link above of this post. JB]

With the advent of a new generation of psychotropic medications, such persons are more easily controlled. But the medications are also capable of masking deep and pervasive illness lurking just under the surface. And it is also well known among healthcare professionals in the field that such patients will often stop taking their medications unless someone is around to make sure they do so.

And without close, daily supervision such as one would find in a mental hospital, no one is there to monitor the management of medications for such persons.

That said, he tosses a few more barbs at Piers Morgan, Mayor Bloomberg and Brian Ross for their presumed advocacy of better gun control, and plugging a couple more non-sequiturs before signing off. 

~~~~~~~~~~~~~~~~~~~~

I don't know how many "isolated incidents" of crazy people blowing up and staging mass killings it will take to wake up enough people to address the problem. But I feel confident in predicting that before 2011 is over the headlines will once again be screaming aboout another tragedy like the one in Tucson. [This was written in the aftermath of the Gabby Gifford shooting. I was wrong about headlines in 2011, perhaps because as time passes we become more numb to the numbers.]  The targets may or may not be elected representatives, or children, or random strangers, or co-workers...there is no way to know in advance where, when and how a crazy person will explode.

But several realities about crazy people have been apparent for years.

• Crazy people can legally buy and use firearms. That crap about "When guns are outlawed only outlaws will have guns" is plainly wrong, as this most recent example illustrates.


• Community mental health resources and aftercare are not preventing crazy people from killing others.


• Deinstitutionalization, which started about forty years ago, is as much a failure as the so-called War on Drugs.  It is time for a reality check for both.


• Everyone I know has personal knowledge of somebody who is crazy. Not eccentric or strange or aloner or with special needs, but out and out card-carrying crazy. Most crazy people are harmless but a relatively small minority are dangerous and are candidates for civil commitment. There are not enough professionals to prevent these crazy people from killing others so it is the responsibility of everyone to take seriously the responsibility to protect themselves and those they care about against the harm that will result if crazy people are not managed properly.


• In the same way that society has learned to confront overt racism, smoking and drunk driving, it is time for a movement to raise the awareness and responsibility of everyone to be more alert to potentially crazy people who need professional attention. Yes, we still have racists, smokers and drunks among us, but those qualities are no longer as acceptable as they were just a few years ago. It's time for ordinary folks to wake up to the dangers of crazy people. As in the case of child abductions and the dangers of fire, there are not enough professionals to fight the problem without help from the public. 

And anyone who thinks this is not about healthcare reform needs to go back and read the memo again.