Pat Moynihan (1999): Deinstitutionalization Failed

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Congressional Record (Bound Edition), Volume 145 (1999), Part 11 - DEINSTITUTIONALIZATION OF THE MENTALLY ILL

Congressional Record (Bound Edition), Volume 145 (1999), Part 11 - DEINS...

    ---Congressional Record (Bound Edition), Volume 145 (1999), Part 11 - DE…

Congressional Record (Bound Edition), Volume 145 (1999), Part 11 - DE…

Patrick Moynihan: Deinstitutionalization Failed : Mental Illness Policy Org

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[Congressional Record (Bound Edition), Volume 145 (1999), Part 11]  [Senate]  [Pages 15539-15541]  [From the U.S. Government Publishing Office, www.gpo.gov]                         DEINSTITUTIONALIZATION OF THE MENTALLY ILL      Mr. MOYNIHAN. 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,    [[Page 15540]]    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.    The articles follow:                    [From the Washington Post, July 9, 1999]                      Deinstitutionalization Hasn't Worked      ``We have lost effectively 93 percent of our state psychiatric hospital                              beds since 1955''                  (By E. Fuller Torrey and Mary T. Zdanowicz)           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 has proven this point.         A 1996 study published in the Journal of Community        Psychology demonstrated that negative attitudes toward people        with mental illnesses increased greatly after people read        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,        underground in subway tunnels or in jails and prisons because        of 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 perpetrators 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 hospital 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. Because 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    [[Page 15541]]         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 3.5 million people        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.                                    ____                      [From the New York Times July 12, 1999]          National Report--Prisons Brim With Mentally Ill, Study Finds                              (By Fox Butterfield)           The first comprehensive study of the rapidly growing number        of emotionally disturbed people in the nation's jails and        prison has found that there are 283,800 inmates with mental        illness, about 16 percent of the jail population. The report        confirms the belief of many state, local and Federal experts        that jails and prisons have become the nation's new mental        hospitals.         The study, released by the Justice Department yesterday,        paints a grim statistical portrait, detailing how mentally        ill inmates tend to follow a revolving door from homelessness        to incarceration and then back to the streets with little        treatment, many of them arrested for crimes that grow out of        their illnesses.         The report found that mentally ill inmates in state prisons        were more than twice as likely to have been homeless before        their arrests than other inmates, twice as likely to have        been physically or sexually abused in childhood and far more        likely to have been using drugs or alcohol.         In another reflection of their chaotic lives, the study        found that emotionally disturbed inmates had many more        incarcerations than other inmates. More than three-quarters        of them had been sentenced to jail or prison before, and have        had served three or more prior sentences.         One of the most striking findings in the study, and the one        most likely to be disputed, is that mentally ill inmates in        state prisons were more likely than other prisoners to have        been convicted of a violent crime. Too, many emotionally        disturbed inmates were arrested for little more than bizarre        behavior or petty crimes, like loitering or public        intoxication, but the report, by the Justice Department's        Bureau of Justice Statistics, did not offer any breakdown on        this category of convictions.         Moreover, once incarcerated, emotionally disturbed inmates        in state prisons spend an average of 15 months longer behind        bars than others, often because their delusions,        hallucinations or paranoia make hem more likely to get into        fights or receive disciplinary reports.         ``This study provides data to show that the incarceration        of the mentally ill is a disastrous, horrible social issue,''        said Kay Redfield Jamison, a professor of psychiatry at the        Johns Hopkins School of Medicine. ``There is something        fundamentally broken in the system that covers both hospitals        and jails,'' said Professor Jamison, the author of ``Night        Falls Fast: Understanding Suicide,'' to be published later        this year by Knopf.         With the wholesale closings of public mental hospitals in        the 1960's, and the prison boom of the last two decades,        jails are often the only institutions open 24 hours a day and        required to take the emotionally disturbed.         The hospitals were closed at a time when new antipsychotic        drugs made medicating patients in the community seem a humane        alternative to long-term hospitalization. From a high of        559,000 in 1955, the number of patients in state hospitals        dropped to 69,000 in 1995.         But drugs work only when taken and many states failed to        build a promised network of clinics to monitor patients. To        compound the problem, for-profit hospitals began turning away        the psychotic, who tend to be more expensive and stay longer        than other patients, and are often without health insurance.         At the same time, the number of jail and prison beds has        quadrupled in the last 25 years, with 1.8 million Americans        now behind bars.         ``Jails have become the poor person's mental hospitals,''        said Linda A. Teplin, a professor of psychiatry and director        of the psycho-legal studies program at Northwestern        University.         After years of inattention by the Government, the problem        has generated a flurry of interest in the Clinton        Administration, led by Tipper Gore and Attorney General Janet        Reno, whose department is sponsoring a major conference on it        next week.         All previous estimates of the number of emotionally        disturbed inmates have been based on research by Professor        Teplin in the Cook County Jail in Chicago. She found that 9.5        percent of male inmates there had experienced a severe mental        disorder like schizophrenia, manic depression or major        depression, four times the rate in the general population.         Professor Teplin said that while she welcomed the Justice        Department count, it was open to question because the study        relied on reports by the inmates themselves, who were asked        whether they had a mental condition or had ever received        treatment for a mental problem. People with emotional        disorders often are not aware of them or do not want to        report them, she said, so the Justice Department estimate of        more than a quarter-million inmates with mental illness may        actually be too low, Professor Teplin said.         In addition, she said, the study was not conducted by        mental health professionals using diagnostic tests, so it was        impossible to tell what mental disorders the inmates suffered        from, and whether they were severe illnesses, like        schizophrenia, or generally less severe problems, like        anxiety disorders.         The study found that 53 percent of emotionally disturbed        inmates in state prisons were sentenced for a violent crime,        compared with 46 percent of other prisoners. Specifically,        13.2 percent of mentally ill inmates in prisons had been        convicted of murder, compared with 11.4 percent of other        prisoners, and 12.4 percent of mentally ill inmates had been        convicted of sexual assault, compared with 7.9 percent of        other prisoners.         Advocates for the mentally ill have worked hard to show        that emotionally disturbed people are no more violent than        others, to try to lessen the stigma surrounding mental        illness. But recent research, while confirming that mentally        ill people may not be more violent than others, suggests that        they can become violent in a number of conditions, including        when they are off their medications or are taking drugs or        alcohol.         In another important finding, also subject to differing        interpretations, the study found that reported rates of        mental illness varied by race and gender, with white and        female inmates reporting higher rates than black and male        inmates. The highest rates of mental illness were among white        female state prisoners, with an estimated 29 percent of them        reporting emotional disorders, compared with 20 percent of        black female prisoners. Overall, 22.6 percent of white state        prisoners were identified as mentally ill, compared with 13.5        percent of black prisoners.         Dr. Dorothy Otnow-Lewis, a psychiatrist, said the        differences were a result of white psychiatrists ``being very        bad at recognizing mental illness in minority individuals.''        Psychiatrists are more likely to dismiss aggressive behavior        in men, particularly black men, as a result of their being        bad, rather than being mad, said Dr. Lewis, who is a senior        criminal justice fellow at the Center on Crime, Communities        and Culture of the Soros Foundation.         Michael Faenza, the president of the National Mental Health        Association, said the study ``shows that the criminal justice        system is just a revolving door for a person with mental        illness, from the street to jail and back without        treatment.''         Professor Jamison noted that jails and prisons are not        conducive to treatment, even when it is available. ``Inmates        get deprived of sleep,'' she said, ``and isolation can        exacerbate their hallucinations or delusions.''                              ____________________

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Patrick Moynihan: Deinstitutionalization Failed : Mental Illness Policy Org Patrick Moynihan: Deinstitutionalization Failed 2 articles Congressional Record – Senate Monday, July 12, 1999 1...